Opioids overdoses now kill more Americans than car accidents or guns, with more than 350,000 Americans having succumbed to the painkillers since 2000.

“The opioid misuse and overdose crisis touches everyone in the United States,” Health and Human Services Secretary Alex Azar said in this recent report. “The effects of the opioid crisis are cumulative and costly for our society — an estimated $504 billion a year in 2015 — placing burdens on families, workplaces, the health care system, states, and communities.”

Now, new research led by Stanford shows that not only have opioid-related deaths jumped fourfold in the last 20 years, but that those most affected by the epidemic, and where they live, has also shifted dramatically. In fact, the District of Columbia has had the fastest rate of increase in mortality from opioids, more than tripling every year since 2013.

“Although opioid-related mortality has been stereotyped as a rural, low-income phenomenon concentrated among Appalachian or midwestern states, it has spread rapidly, particularly among the eastern states,” writes Mathew V. Kiang, ScD, a research fellow at the Center for Population Health Sciences at the Stanford University School of Medicine, in an original investigation published in JAMA Network Open.

The study found the highest rates of opioid-related deaths and more rapid increases in mortality were observed in eight states: Connecticut, Illinois, Indiana, Massachusetts, Maryland, Maine, New Hampshire and Ohio. Two states, Florida and Pennsylvania, had opioid-related mortality rates that were doubling every two years — and tripling in Washington, D.C.

Kiang and his co-authors, including Stanford Health Policy’s Sanjay Basu, MD, PhD,an assistant professor of medicine at Stanford Medicine, used data from the National Center for Health Statistics and corresponding population estimates from the U.S. Census. The other authors are Jarvis Chen, ScD, at the Harvard T.H. Chan School of Public Health, and Monica Alexander, PhD, in the Department of Sociology at the University of Toronto.

“It seems there has been a vast increase in synthetic opioid deaths in the eastern states and especially in the District of Columbia because illicit drugs are often tainted with fentanyl or other synthetic opioids,” Kiang said in an interview.  “People aren’t aware their drugs are laced and more potent than they expected — putting them at higher risk of overdose.”

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Synthetic opioid deaths now outnumber heroin deaths in these eastern states, which suggests fentanyl has spread to other illegal drugs and is no longer limited to heroin.

“The identification and characterization of opioid `hot spots’ — in terms of both high mortality rates and increasing trends in mortality — may allow for better-targeted policies that address the current state of the epidemic and the needs of the population,” the authors write.

The research suggests the opioid epidemic has evolved as three intertwined, but distinct waves, based on the types of opioids associated with mortality:

1. The first wave of opioid-related deaths was associated with prescription painkillers from the 1990s until about 2010.
2. From 2010 until the present, the second wave was associated with a large increase in heroin-related deaths.
3. And in the third and current wave, which began around 2013, the rapid increase is associated with illicitly manufactured synthetic opioids, such as tramadol and fentanyl.

“The evolution has also seen a wider range of populations being affected, with the spread of the epidemic from rural to urban areas and considerable increases in opioid-related mortality observed in the black population,” they write.

The Centers for Disease Control and Prevention reports that African-Americans experienced the largest increase in opioid overdose deaths among any racial group from 2016 to 2017, with a 26 percent surge.

“The identification and characterization of opioid ‘hot spots’ — in terms of both high mortality rates and increasing trends in mortality — may allow for better-targeted policies that address the current state of the epidemic and the needs of the population,” the researchers write.

States are trying to combat the epidemic by enacting policies, such as restricting the supply of prescription drugs and expanding treatment and access to the overdose-reversing drug naloxone.

“Treating opioid use as a disorder should be our top priority to curb the problem,” said Kiang. “Similarly, we have the ability that counteract the effects of an overdose — these life-saving drugs should be easily accessible and widely available.”