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Fact Sheet: The Opioid Overdose Epidemic in the United States

Compiled by Megan J. Wolff, PhD MPH
Last Updated: April 5, 2018


Findings indicate that the opioid overdose epidemic is worsening.1

  • U.S. overdose deaths from 2002-2015 (NIH/NIDA)

  • Opioid overdose deaths have resulted in the first two-year drop in average U.S. life expectancy since the early 1960s. 2
    • U.S. life expectancy is now lower than in most high-income countries. The gap is projected to increase. 3

  • Deaths Opioid overdose visits to hospital emergency departments increased more than 30% from third quarter 2016 to third quarter 2017. 4
    • The increase occurred across all 5 U.S. regions and all demographic groups.
    • The increase suggested a worsening of the epidemic into late 2017.

  • Synthetic opioids such as fentanyl have become a main driver of the epidemic.
    • According to the CDC, the number of fentanyl encounters more than doubled from 5,343 in 2014 to 13,882 in 2015. 5

A Timeline of the Epidemic

2009

  • Drug overdose, principally due to opioids, became the leading cause of injury-related death.
    • 15,597 deaths involved an overdose of prescription opioids.
    • 3,278 deaths involved an overdose of heroin.

2010

  • 1,088 Americans died of an overdose involving an opioid.*
    • 16 651 deaths involved an overdose of prescription opioids.
    • 3,036 deaths involved an overdose of heroin.
      *(Because more than one drug can be assigned causality in a single death, an individual death may be reflected multiple times.)

2011

  • The death rate associated with opioid analgesics began to stabilize with a decline in opioid prescribing, but the rate due to heroin overdose increased sharply.

  • 22,784 Americans died of an overdose involving an opioid.
    • 16,917 deaths involved an overdose of prescription opioids.
    • 4,397 deaths involved an overdose of heroin.

2012

  • 23,164 Americans died of an overdose involving an opioid.
    • 6,007 deaths involved an overdose of prescription opioids.
    • 5,932 deaths involved an overdose of heroin.

2013

  • 25,050 Americans died of an overdose involving an opioid.
    • 16,235 deaths involved an overdose of prescription opioids.
    • 8,257 deaths involved an overdose of heroin.

2014

  • More persons died from drug overdoses in the United States in 2014 than during any previous year on record. 6

  • Deaths from opiate-related overdose outnumbered deaths from car accidents. 7

  • The age-adjusted rate of death increased 26% for heroin, and 80% for synthetic opioids such as fentanyl. The increase coincided with law enforcement reports of increased availability of illicitly manufactured fentanyl. 7
    • From August 2013 through the end of 2015, U.S. law enforcement agencies seized more than 239 kilograms of illicitly produced fentanyl.8
    • Between late 2013 and late 2014 alone, there were over 700 deaths related to fentanyl in the United States, and this figure is largely believed to be underestimated due to variations in state reporting techniques and deaths being attributed to heroin.

  • 28,647 Americans died of an overdose involving a prescription or illicit opioid.
    • 18,893 deaths involved an overdose of prescription opioids.
    • 10,574 deaths involved an overdose of heroin.
    • More than 700 deaths involved the presence of fentanyl. 9

  • American hospitals reported 1.27 million emergency room visits and inpatient stays for opioid-related issues. 10
    • These figures reflect a 64% increase for inpatient care and a 99% increase for emergency room treatment compared to figures from 2005.
    • The rate of opioid-related ED visits approximately doubled for both sexes.

2015

  • More than 2 million Americans had an opiate use disorder. 11

  • The rate of deaths involving heroin and synthetic opioids such as fentanyl continued to increase sharply across many states.

  • 33,091 Americans died of an overdose involving a prescription or illicit opioid.
    • 22,598 deaths involved an overdose of prescription opioids.
    • 12,989 deaths involved an overdose of heroin.

2016

  • 64,070 Americans died of an overdose involving a prescription or illicit opioid 12
    • 14,427 deaths involved an overdose of prescription opioids.
    • 15,446 deaths involved an overdose of heroin.
    • 20,145 deaths involved an overdose of synthetic opioids such as fentanyl.

  • Much of the increase in the rate of death was due to synthetic opioids such as fentanyl.
    • The fentanyl death rate doubled since 2015.
    • The difference was large enough to account for nearly all the increase in drug overdose deaths from 2015 to 2016. 13
    • The Drug Enforcement Administration (DEA) announced in July that hundreds of thousands of counterfeit prescription pills were known to have entered the U.S. drug market since 2014, some containing deadly amounts of fentanyl and fentanyl analogs.

  • The five states with the highest rates of death due to drug overdose were: 14
    • West Virginia (52.0 per 100,000)
    • Ohio (39.1 per 100,000)
    • New Hampshire (39.0 per 100,000)
    • Pennsylvania (37.9 per 100,000)
    • Kentucky (33.5 per 100,000)

2017


  • Attorney General Jeff Sessions estimated that the epidemic cost the government $115 billion this calendar year, and predicted that it could cost the United States an additional $500 billion over the next three years. 15

  • A bipartisan coalition of 41 attorneys general from across the country served subpoenas in September for information and documents from the manufacturers and distributors of prescription opioid drugs, part of a multistate investigation into whether the companies engaged in unlawful practices in the marketing and distribution of prescription opioids. 16

  • In December, the U.S. Judicial Panel on Multidistrict Litigation consolidated over 200 federal lawsuits over the nation's opioid crisis and appointed Judge Dan Aaron Polster of the Northern District of Ohio to preside over them.

2018

  • Attorney General Jeff Sessions announced the creation of a Prescription Interdiction & Litigation Task Force (PIL) to pursue the makers and distributors of prescription opioids and to examine existing lawsuits against opioid manufacturers. 17



    • Further information

    • It has become widely accepted that a rise in physician prescribing helped cause the current opioid epidemic. 18
    • Individuals with opiate-related substance use disorders are most often introduced to opioids through the use of prescription drugs.
      • An increase in the availability of prescription opiates has fueled a rise in addiction nationally. 19
        • The use of prescription opioid analgesics increased substantially from 2002 through 2010, then plateaued in 2011, with some suggestion of decrease. 20
    • Much of this increase was attributable to the use of opiates in the management of chronic non-cancer pain.
    • Chronic use of opioid agonists can result in opioid-induced hyperalgesia, whereby patients develop an increased sensitivity to pain due to their use of opioids.

    Opioid use disorder frequently begins in adolescence and young adulthood.

    • 7.8% of high school seniors reporting lifetime nonmedical prescription opioid use. 21
    • Two-thirds of individuals under treatment report that their first use was before age 25. 22
    • One-third report that their first use occurred before 18 years. 23

    The Role of Heroin

    • Heroin use has been increasing in the United States since 2007. 24
      • National surveillance data demonstrated a 145% increase (to 914,000) in the number of people who reported heroin use since 2007. 25
      • Between 2007 and 2015 the number of past-year heroin users increased from 373,000 to 828,000. 26
    • Efforts to reduce prescription-opioid abuse and overdose have coincided with reported increases in the rates of heroin use and overdose (including both injection and noninjection drug administration). 27
      • That is, policies such as drug reformulation and prescription monitoring that have been designed to address inappropriate prescribing may now be paradoxically fueling the increases in rates of heroin use and death. 28
      • From 2010 to 2012, the death rate from heroin overdose for 28 states increased from 1.0 to 2.1 per 100,000, whereas the death rate from prescription opiate overdose declined from 6.0 per 100,000 in 2010 to 5.6 per 100,000 in 2012. 29
    • Studies since 2003 have documented a pathway between the non-medical use of prescription opioids and the initiation of heroin use. 30
      • Increases in a hospital’s prescription overdose admissions predict an increase in the subsequent years’ heroin overdose admissions by a factor of 1.57. 31
      • Many patients who initiate heroin use have come to view heroin as more reliably available, potent, and cost-effective than prescription opioids. 32
        • The retail price of heroin has been lower than $600 per pure gram every year since 2001, with costs of $465 in 2012 and $552 in 2002, as compared with $1237 in 1992 and $2690 in 1982. 33

    The Role of Fentanyl

      • Fentanyl is a synthetic opioid 50-100 times more potent than heroin and far less expensive to produce.
        • The wholesale cost of heroin is about $65,000 per kilogram, whereas illicit fentanyl is available at roughly $3,500 per kilogram. 34
      • Fentanyl and its analogs (e.g., carfentanil) is now recognized as a major contributor to increases in opioid overdose mortality. 35
        • From 2012 through 2014, the number of reported deaths involving fentanyl more than doubled, from 2628 to 5544. 36
        • Increases were especially pronounced among males aged 15-44. 37
      • The observed increase in fentanyl deaths is not correlated with an increased fentanyl prescription rate or with an increase of pharmaceutical fentanyl being diverted from legitimate medical use to illegal uses. 38
      • The epidemic is based on a rise in illicitly manufactured fentanyl and fentanyl analogs, commonly mixed with or sold as powdered heroin, or as counterfeit pharmaceuticals including Oxycontin, Xanax, Norco and other tablets. 39
      • Many people who die from fentanyl overdose appear to have been unaware that they were using the drug. 40

    Treatment

    • More than 1.2 million people meet the diagnostic criteria for an opioid use disorder (OUD) but do not receive treatment. 41
    • Despite the fact that OUD often begins in adolescence, only 1 in 12 young adults who need addiction care receive treatment. 42
    • Only 1 in 4 (26.8%) of youth receive recommended pharmacotherapy (either buprenorphine or naltrexone) within 6 months of diagnosis. 43

    Naloxone

    Naloxone is a potent opioid antagonist that is FDA approved for emergency treatment of known or suspected opioid overdose. Naloxone has no effect in people who are not taking opioids. Administered correctly, Naloxone can reverse the effects of overdose.

    • Overdose education and community naloxone distribution (OEND) is a primary strategy in preventing deaths due to the opioid epidemic. 44
      • Forty-seven states have expanded access to naloxone in some form.45
      • The legal framework in most states now promotes access to naloxone kits through standing, often state-wide, prescriptions at retail pharmacies or by allowing health professionals to prescribe naloxone to third-party family members. 46
        • Naloxone prescriptions dispensed at US retail pharmacies have risen steeply since 2013. 47
      • Bystanders who may be in a position to administer Naloxone include those who use opioids themselves, friends, family members, acquaintances, or first responders such as police, EMT, or fire personnel. 48
      • Studies have demonstrated successful reductions in mortality due to the implementation of OEND. 49

    Buprenorphine

    Buprenorphine is a mixed narcotic agonist-antagonist. It helps prevent withdrawal symptoms caused by stopping other opiate-type narcotics. Approved for clinical use in 2002, it is available in both daily oral formulations and as a long-acting implant.

    • There is substantial, strong, and reproducible evidence that medication-assisted treatment of opioid use disorder improves mortality and reduces opioid use, and that such therapies are more effective than counseling alone. 50
    • Buprenorphine is the most commonly prescribed medication for opioid use disorder treatment.
      • It is effective in managing withdrawal symptoms and reducing the potential for relapse. 51
      • It has relatively high rate of patient retention and sustained recovery. 52
      • Buprenorphine is the only type of medication-assisted treatment that can be dispensed outside of traditional stand-alone programs such as methadone clinics.
        • It has the capacity to improve treatment access for individuals unable or unwilling to receive methadone. 53
    • Limitations
      • Access to medication-assisted treatment is lacking across much of the United States. 54
      • Historically the majority of individuals with opioid use disorders have not received opioid agonist treatment. 55
      • Buprenorphine can only be prescribed by waivered physicians.
        • Providers must have board certification in addiction medicine/psychiatry or have completed an 8-hour course of prescribing training.
        • Providers may treat only a limited number of individuals.
          • Evidence suggests that policies which relax patient limits may be more effective in increasing buprenorphine use than alternatives such as opening new treatment facilities or increasing the number of waivered physicians. 56
        • 2006 Federal legislation raised the number from 30 to 100
        • 2016 Federal legislation (CARA) increases the number from 100 to 275 and expands prescribing privileges to nurse practitioners and physician assistants.
      • The cost of Buprenorphine is $6000 for a full year treatment course. 57

    Health insurance

    Research shows that health insurance coverage makes care more affordable, secure, and reliable, and that people with insurance are more likely to get timely and consistent care. 58

    • In 2016, 39% of people suffering with illicit drug use disorders reported that they had no health insurance coverage and could not afford the cost of treatment. 59
    • Changes implemented through the Affordable Care Act have been especially important to people with substance use disorders and other behavioral health conditions.
      • Parity. Prior to the ACA, an estimated 34 percent of individual market policies did not cover substance use treatment. 60
      • Expansion of Health Insurance Coverage. Among low-income adults, Medicaid expansion was associated with an 18.3 percent reduction in unmet need for substance use disorder treatment services. 61
        • States that made an early commitment to expand Medicaid and establish insurance Marketplaces had significantly higher growth in the number of physicians with a waiver to prescribe buprenorphine for opioid use disorder treatment. 62

    The Comprehensive Addiction and Recovery Act (CARA)

    • On July 22, 2016, President Obama signed into law the Comprehensive Addiction and Recovery Act (CARA). (P.L. 114-198).
      •  
      • This is the first major federal addiction legislation in 40 years, and the most comprehensive effort undertaken to address the opioid epidemic.
      • The bill passed the U.S. Senate on March 10, 2016, by a vote of 94-1. The bill passed the U.S. House of Representatives on May 13, 2016, by a vote of 400-5.
    • Provisions extended through CARA include: 63
      • Grants to expand state prescription drug monitoring programs.
      • Authorization for collaboration between the Centers for Medicare & Medicaid Services and prescription drug plans, as well as private health plans, to monitor and curb opioid misuse.
      • Increase in the number of patients a healthcare provider may prescribe buprenorphine to from 100-275.
      • Expansion of prescribing privileges to nurse practitioners (NPs) and physician assistants (PAs) for five years (until October 1, 2021).
      • Implementation of evidence-based treatment and intervention programs for incarcerated individuals.
      • Provision of safe disposal sites for unused prescription medications Initiation of medication assisted treatment programs for pain management.
    • CARA  authorizes over $181 million each year in new funding to fight the opioid epidemic, but monies must be appropriated every year, through the regular appropriations process, in order for it to be distributed in accordance with the law. 
      • Without appropriations, CARA is a powerful statement but not necessarily an actionable plan.

    Recommended Analysis:

    Colleen Walsh, Rising threat: Death by fentanyl; MGH addiction specialist Sarah Wakeman explains synthetic opioid's role in U.S. epidemic," Harvard Gazette, 6/27/2017.


    References

    1. Statistical Data in the below timeline is taken from the table, “National Overdose Deaths from Select Prescription and Illicit Drugs” available through the NIH National Institute on Drug Abuse site ; See also National Center on Health Statistics, CDC WONDER.
    2. Opioid Crisis Trims U.S. Life Expectancy, Boosts Hepatitis C: CDC, Reuters (Dec. 21, 2017)
    3. Kontis V, Bennett JE, Mathers CD, Li G, Foreman K, Ezzati M. Future life expectancy in 35 industrialized countries: projections with a Bayesian model ensemble. Lancet. 2017389(10076):1323-1335.
    4. Vivolo-Kantor AM, Seth P, Gladden RM, et al. Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses — United States, July 2016–September 2017. MMWR Morb Mortal Wkly Rep 2018;67:279–285.
    5. Reported Law Enforcement Encounters Testing Positive for Fentanyl Increase Across US
    6. Rudd RA, Seth P, David F, Scholl L, “Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015,” MMWR Morb Mortal Wkly Rep. 2016 Dec;65(5051):1445-1452.
    7. Press release: “HHS takes strong steps to address opioid-drug related overdose, death and dependence.”
    8. Rudd RA, Aleshire N, Zibbell JE, Gladden RM., “Increases in Drug and Opioid Overdose Deaths--United States, 2000-2014,” MMWR Morb Mortal Wkly Rep. 2016 Jan 1;64(50-51):1378-82.
    9. This number is largely believed to be underestimated due to variations in state reporting techniques and the misattribution of fentanyl deaths to heroin.
    10. Weiss, AJ, Bailey, MK, O’Malley, L, Barrett, ML, Elixhauser, A, Steiner, CA, “Patient Characteristics of Opioid-Related Inpatient Stays and Emergency Department Visits Nationally and by State, 2014” Agency for Healthcare Research and Quality, Statistical Brief #224, June 17, 2017.
    11. " Continuing Progress on the Opioid Epidemic: the Role of the ACA," ASPE Issue Brief, Washington, DC: U.S. Department of Health & Human Services, January 11, 2017.
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    13. US Centers for Disease Control and Prevention. Provisional counts of drug overdose deaths as of August 6, 2017.
    14. Hedegaard H, Warner M, Miniño AM. Drug overdose deaths in the United States, 1999–2016. NCHS Data Brief, no 294. Hyattsville, MD: National Center for Health Statistics. 2017/ CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016.
    15. Attorney General Sessions Delivers Remarks Announcing the Prescription Interdiction and Litigation Task Force. Justice News, February 27, 2018.
    16. Eric T. Schniederman Press Release, Sept 19. 2017 “A.G. Schneiderman, Bipartisan Coalition Of AGs Expand Multistate Investigation Into Opioid Crisis”
    17. Dept. of Justice, Office of Public Affairs, “Justice Department to File Statement of Interest in Opioid Case” Press Release Number 18 – 243, February 27, 2018.
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    22. Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS): 2003-2013 National Admissions to Substance Abuse Treatment Services. Rockville, MD: Drug Abuse Warning Network; 2015.
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