Opioids 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.

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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.

Talia 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.

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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    • I’m glad you asked:
      “Naloxone blocks the effects of opioid medication, including pain relief or feelings of well-being that can lead to opioid abuse. Buprenorphine and naloxone is a combination medicine used to treat narcotic (opiate) addiction. Buprenorphine and naloxone is not for use as a pain medication.”

  • Has anyone thought about the number of patients with severe chronic pain from diseases like Interstitial cystitis which I have had since 1989 which has no cure and no preferred treatment that works for patients like me. I have worked with my doctor for 22 years to come up with a pain treatment that has made my life bearable and now it’s getting more and more difficult to get my prescriptions. The supplier of my medicine has stopped making the drug so I just had to change to a different medicine and I don’t know if it will work or if I am going to have a reaction to it like I have with morphine where I itch everywhere. What is going to happen with patients that have severe pain that can’t get a doctor to prescribe pain medicine anymore is they will go to illegal drugs that are even more dangerous than prescription drugs. I personally couldn’t find a doctor that would prescribe pain medication until I found my current doctor. My life was total hell and I thought about suicide daily. The only thing that helped a little was a hot bath. I would be in the tub every hour or so and the other time I would be in bed in a fetal position. I don’t sleep very much even now because I am in the bathroom urinating every fifteen minutes 24 hours a day. I panic thinking about the day my doctor retires which could be within the next year or two or the next visit when he tells me he can no longer prescribe any pain medicine or my pain medicine is no longer availiable. I do know that I will not go back to a day without pain medication. I will end my life rather than suffer again. I hope all these lawyers suing the pharmaceutical companies understand the consequences of their actions because there are many patients that need those pain medicines and I hope they don’t find out what it is like having severe unrelenting pain.

    • Lest anyone read the above comment with skepticism, let me assure you this is absolutely real. Having to use the bathroom every 15 minutes around the clock is not unheard of for severe refractory IC.

      The cause is unknown, but it’s thought to have multiple subtypes, based on the fact that no treatment helps more than 50-some percent of patients in clinical trials. The autoimmune subtype is particularly challenging, as the most effective treatment in clinical trials is cyclosporine – a long-term risk profile worse than long-term opioids.

      The animal model of this disease involves catheterizing mice and injecting hydrochloric acid. (You can imagine how the mice react.)

      However, with high-dose opioid pain medication, even IC patients who have failed 40-50 alternative treatments (including multidisciplinary pain programs) can live essentially normal lives, indistinguishable from anyone else.

      Increasing access to addiction treatment, including medication for addiction, is essential. At the same time, any policy discussion involving opioid prescribing must also include people with physical disabilities. Opioid medication can be a necessary disability accommodation – allowing people to leave their homes, succeed in professional careers, and care for their families.

  • This passes as/for breaking, alarming “news” ?

    The fact that America has a very nasty illegal drug use habit (cocaine, Methamphetamine, Alcohol) that accounts for 1,000X greater fatalities/deaths (and OD deaths) than ANY Physician-prescribed opiate regime EVER has -or will.

    Soooo, maybe you should do some basic research and display/overlay the staggering data that cocaine, methamphetamine and alcohol abuses account for.
    If you were to do this, opiate deaths -and nothing but prescribed opiates involved- the numbers would be comparatively near ZERO; it wouldn’t even register on a (visual) graph.

    How about talking about the governments impotency in finding and prosecuting dangerous street-drug organizations that cater to illegal drug users and abusers ?

    Instead, the media gets suckered into this (Opiate Crisis BS) diversion that has and will continue to DESTROY legitimate intractable pain sufferer’s lives.

    It’s time for honesty, revealing the real issues, and initiating a sensible plan to address the alarming rise in illicit drug use -and deaths, that result.

    peter jasz

  • Well-said, Richard. Legitimate chronic pain patients are NOT the problem. The misguided attempt to lump us all together with the illegal drug business and junkies who are determined to chase that next high anywhere and any way they can find it, is indicative of how little many people understand about the difference. All they hear is “Drugs… BAD!” I’m 70 years old, my back is wrecked, and my MRIs prove it. Now I’ve also got bursitis. I hurt every day, all the time, but my 45 mgs of oxycodone keep me functional… a dosage that hasn’t escalated in years. Why am I now made to feel like a junky when I go to get my prescription filled? Why am I lumped into the same category as junkies shooting up heroin or fentanyl that they purchased in some dark alley? At my age, does anybody think I should be terribly concerned about suddenly dying from a drug I’ve successfully taken for the last eight years. I’M not the problem here… the Government is.

  • Like some others in this comment thread, I have published extensively on issues of chronic pain and addiction. I am a technically trained non-physician patient advocate with 22 years experience moderating online forums and analyzing literature for chronic pain communities. From this background, I commend a reading of my recent article on the respected blog of Dr Lynn Webster, past president of the American Academy of Pain Medicine: “Over Prescribing Did Not Cause the Opioid Crisis”.

    Published data of the CDC flat-out disprove the silly notion that doctors over-prescribing for people in pain “caused” our present public health crisis. Overdose mortality has no cause and effect relationship to prescribing rates, and the demographics of addiction versus chronic pain are almost entirely disjoint. Our crisis is instead driven by illegal street drugs aggressively marketed by cartels, in areas of the country where communities have been hollowed out by economic stagnation and despair. The contribution of medically managed opioids is so small that it gets lost in the noise. Even when metabolic byproducts of prescription-type opioids are found in postmortum tox screens, they are almost always found with alcohol and/or illegal drugs.

    There is evidence enough of misbehavior in marketing by large pharma companies during the late 1990s through 2010. But despite this misbehavior, medically prescribed opioids have had almost no impact on overdose related mortality. NIDA Director Dr Nora Volkow has written with a coauthor that “unlike tolerance and physical dependence, addiction is not a predictable result of opioid prescribing. Addiction occurs in only a small percentage of persons who are exposed to opoids — even among those with pre-existing vulnerabilities.”

    Likewise, “opioid-related hyperaestheia” has never been demonstrated in humans (only animal models). As in many other areas of human experience, in the so-called “opioid crisis”, it’s amazing how much of what everybody knows ain’t so.

  • It is not the prescription pharmaceutical opioids that is killing people it is the street opioid fentanyl that is killing people. Why do I know hear anyone saying this when it is the truth. Government wants to have patients who are on pain medication suffer and stop all opioid when the real problem is the street fentanyl that is the problem

    • Ken, what you are saying is so true. I have done many studies and research on opioid deaths and what I found is very few opioid deaths are caused by prescription Norco/Vicodin opioid drugs. Most opioid deaths are from illegal fentanyl opioid drugs. This is not fair to the millions of legitimate people in pain suffer. STOP THE SUFFERING

  • I have posted often on this site about the safety & benefits of buprenorphine, yet still see a lot of posts like Shirley’s. Any doc can Rx Sched lll meds for pain without a wavier. In 18 years, only one person died using buprenorphine alone, It is effective for most pain and develops little tolerance. Dosage varies with metabolic rates. Why aren’t you bugging your doc for it or talking to the pain docs about it? Wouldn’t have an epidemic if we were using it for pain. Slow withdrawal with med help works without significant withdrawal. Questions? Use email.

    • Thank you, doctor. Buprenorphine is also an important medication assisted treatment (MAT) drug. I am the author of 3 educational books for classrooms about the opioid epidemic and also have written some nonfiction articles for @medium about OxyContin Sacklers and the fentanyl crisis. The words that Shirley is using are almost the exact words used in internal Purdue Pharma documents which were meant to market increased prescriptions for OxyContin both to physicians and patients. I see and hear this same wording from long-term pain patients both as individuals, and through their advocacy websites, who believe they are being abandoned with no pain relief. Research seems to show that most opioids not only develop dependency, they also reduce the body’s ability to cope with pain, and increase sensitivity to pain. I find it unconscionable that this has been allowed to continue for 20+ years. Saddest of all is that, you are right – buprenorphine will likely help many people – but during this 20 year period, little to no research in other ways to relieve pain, whether through prescribed medication or other methods, was accomplished. I am glad to receive the verbal abuse from long-term pain patients who’ve been on ever-escalating prescriptions for opioids, up to fentanyl and in some cases, sufentanil if it means education will occur and there will be some future hope for actual pain relief without dire health consequences. Hey Shirley? You’re addicted. It’s not your fault, but you’re not just dependent, you are addicted by the nature of human biology, especially womens’ biology and these evil companies who made addicted drugs that by their nature – lose their effectiveness over time and create dependency and addiction. I’m sorry.

  • Clearly this article shows only one side of the opioid crisis being addressed!
    There’s another side which involves patients like myself living with chronic pain. Where are the governments morals when it comes to us. I myself am long standing patient in pain management who through trail and error with several alternative treatments and medications, found pain medication the most effective. We don’t abuse medication, yet we’ve been grouped into the same category as addicts now. The stigma for them at least is diminishing and being seen as a disease. How about the The medically diagnosed patients left in sheer agony because the government has decided to adapt guidelines as law.
    When will this side be addressed? Also where are the Guidelines for pain management doctors? PCPs have them for acute pain. Once that treatment runs it’s course of three months that patient is referred to a specialist. So how are they especially the ones already being treated for years after trial and error supposed to receive proper care? Most are having other health issues which have led to death! Symptoms that force them into the ERs and once there- still no relief because we’re labeled as addicts, drug seeking and worse.
    How about you start focusing some needed attention on the law abiding citizens who have done nothing wrong except have a disease, disorder, complications from surgeries or better yet inherited causes.
    Why doesn’t someone step up and begin to work with us instead of casting us aside to suffer? The CDCs guidelines clearly state that after treatment from PCPs for three months of acute pain they be referred to pain management- where’s their care? Along with everyone else already there for years and having gone through several alternatives unsuccessfully.

    • It is not the prescription pharmaceutical opioids that is killing people it is the street opioid fentanyl that is killing people. Why do I know hear anyone saying this when it is the truth. Government wants to have patients who are on pain medication suffer and stop all opioid when the real problem is the street fentanyl that is the problem

  • No. It is NOT “like cigarettes.” Cigarettes are not a required disability accommodation for any medical condition. Cigarettes cannot turn homebound chronically ill patients into functioning members of society after all other therapy fails. Opioid medication – when prescribed selectively and carefully, with appropriate safeguards – can.

    Also, PLEASE stop using prescription bottle imagery for these articles. This imagery is ableist and stigmatizing to people who did nothing to deserve it (except be born with a rare, incurable, and excruciatingly painful disease).

    • It is not the prescription pharmaceutical opioids that is killing people it is the street opioid fentanyl that is killing people. Why do I know hear anyone saying this when it is the truth. Government wants to have patients who are on pain medication suffer and stop all opioid when the real problem is the street fentanyl that is the problem

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