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The Spiraling Opioid Epidemic in America

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US Opioid Epidemic Spiral in America

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The Spiraling Opioid Epidemic in America

Over the last 20 years, the ongoing U.S. opioid crisis has claimed tens of thousands of lives. In fact, opioid overdose deaths accounted for nearly 70% of all drug overdose deaths in 2018.

Although the damage of the opioid epidemic is well documented, what people might not know is that it has escalated in three distinct waves.

We pull the latest statistics from the UN World Drug Report 2020 to uncover the scope of the opioid crisis in the U.S., and how national drug-related death rates compare to other countries.

Three Waves of the Opioid Crisis

According to the CDC, the opioid epidemic can be traced back to the 1990s, when opioids started being over-prescribed for pain relief purposes.

  • 1990s – Wave 1
    Over-prescription of opioids for pain relief, including natural opioids, semi-synthetic opioids, and methadone. Addiction risks were widely downplayed.
  • 2010 – Wave 2
    Heroin-related overdose deaths on the rise.
  • 2013 – Wave 3
    Synthetic opioid-related deaths on the rise, particularly fentanyl and tramadol.

Here’s how that breaks down in terms of opioid-related overdose deaths over the years. Note that by the year 2018, 67% of overdose deaths involved synthetic opioids such as fentanyl.

YearAny opioidsHeroinPharmaceutical opioidsSynthetic opioids
19998,0501,9603,533730
20008,4071,8423,903782
20019,4961,7794,935957
200211,9202,0896,7741,295
200312,9402,0807,8391,400
200413,7561,8789,0761,664
200514,9182,00910,2341,742
200617,5452,08812,4232,707
200718,5162,39913,6762,213
200819,5823,04114,0432,306
200920,4223,27814,4312,946
201021,0893,03615,5203,007
201122,7844,39716,1112,666
201223,1665,92515,0722,628
201325,0528,25713,9373,105
201428,64710,57415,5595,544
201533,09112,98916,0289,580
201642,24915,46917,86019,413
201747,60015,48217,68928,466
201846,80214,99615,57531,335

Overdose deaths from synthetic opioids such as fentanyl and tramadol shot up by over 4,000% between 1999-2018. This can be attributed to two things: their relative potency, and the minute quantities of each that qualify as a lethal dose.

As per the medical and legal standard, opioids are often compared to morphine. To that end, heroin is 2-5x stronger—while fentanyl is 50-100x more potent. Put another way, roughly a dime-size or 10-12mg of heroin is considered a lethal dose, compared to only 1-2mg of fentanyl.

What’s worse, fentanyl is typically mixed with other types of drugs such as heroin or cocaine to increase their effects, which is how it ends up unintentionally ingested. Between 2008-2017, drug-use disorders as a whole claimed the most healthy lives due to poor health or early deaths—measured in disability-adjusted life years (DALYs)—followed in close second by opioid use disorders.

The Death Toll of U.S. Drug Overdoses

It’s undeniable that the opioid epidemic in America has caused significant harm to communities. But how does the U.S. drug crisis compare to the same issue in other countries?

The UN Drug Report further puts these numbers into perspective by comparing drug-related deaths per million population. Note that the source also compiled the total deaths across years for selected countries.

Country (Latest Year)Latest Years of EstimateTotal DeathsRate per 1M (Aged 15-64)
🇺🇸 U.S.201867,367314.5
🇦🇺 Australia2016-20173,240202.6
🇸🇻 El Salvador2018765184.5
🇨🇦 Canada 20184,460179.8
🇺🇾 Uruguay2016264119.4
🇮🇸 Iceland2012-201623105.2
🇸🇪 Sweden201757592.9
🇳🇿 New Zealand201626988.6
🇫🇮 Finland201728983.9
🇬🇧 UK20173,54783

With 314.5 deaths per million, the U.S. by far had the highest proportion of drug-related deaths per million people in 2018. It also had the highest overall number at 67.4K deaths.

Elephant in the Room?

Another drug rearing its head on the streets is carfentanil. Formerly developed as ‘elephant tranquilizer’, this synthetic opioid is similar in appearance to other illicit drugs such as heroin, making it indistinguishable when mixed in. However, there’s one big problem—carfentanil is 100x more potent than fentanyl itself.

In response to the continued crisis, an additional $35.7 billion was requested for counter-drug funding efforts in the FY2021 Budget. This amount is expected to go towards prevention and treatment efforts ($18.6 billion) and law enforcement efforts ($17.1 billion) both domestically and internationally.

But will these efforts properly combat the crisis, or are we already in the midst of a fourth wave of the opioid epidemic?

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Visualized: A Global Risk Assessment of 2021 And Beyond

Which risks are top of mind in 2021? We visualize the World Economic Forum’s risk assessment for top global risks by impact and livelihood.

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Visualized: A Global Risk Assessment of 2021 And Beyond

Risk is all around us. After the events of 2020, it’s not surprising that the level and variety of risks we face have become more pronounced than ever.

Every year, the World Economic Forum analyzes the top risks in the world in its Global Risks Report. Risks were identified based on 800+ responses of surveyed leaders across various levels of expertise, organizations, and regional distribution.

Which risks are top of mind in 2021?

The World’s Top Risks by Likelihood and Impact

According to WEF’s risk assessment methodology, all the global risks in 2021 fall into the following broad categories:

  • 🔵 Economic
  • 🟢 Environmental
  • 🟠 Geopolitical
  • 🔴 Societal
  • 🟣 Technological

It goes without saying that infectious diseases have now become one of the top societal risks on both metrics of likelihood and impact.

That said, environmental risks continue to dominate the leaderboard, accounting for five of the top 10 risks by impact, especially when it comes to climate action failure.

Several countries are off-track in meeting emissions goals set by the Paris Climate Agreement in 2015, while the pandemic has also delayed progress in the shift towards a carbon-neutral economy. Meanwhile, biodiversity loss is occurring at unprecedented rates.

RankTop Risks by LikelihoodTop Risks by Impact
#1🟢Extreme weather🔴Infectious diseases
#2🟢Climate action failure🟢Climate action failure
#3🟢Human environmental damage🟠Weapons of mass destruction
#4🔴Infectious diseases🟢Biodiversity loss
#5🟢Biodiversity loss🟢Natural resource crises
#6🟣Digital power concentration🟢Human environmental damage
#7🟣Digital inequality🔴Livelihood crises
#8🟠Interstate relations fracture🟢Extreme weather
#9🟣Cybersecurity failure🔵Debt crises
#10🔴Livelihood crises🟣IT Infrastructure breakdown

As for other risks, the prospect of weapons of mass destruction ranks in third place for potential impact. In the global arms race, a single misstep would trigger severe consequences on civil and political stability.

New Risks in 2021

While many of the risks included in the Global Risks Report 2021 are familiar to those who have read the editions of years past, there are a flurry of new entries to the list this year.

Here are some of the most interesting ones in the risk assessment, sorted by category:

Societal Risks

COVID-19 has resulted in a myriad of knock-on societal risks, from youth disillusionment and mental health deterioration to livelihood crises. The first two risks in particular go hand-in-hand, as “pandemials” (youth aged 15-24) are staring down a turbulent future. This generation is more likely to report high distress from disrupted educational and economic prospects.

At the same time, as countries prepare for widespread immunization against COVID-19, another related societal risk is the backlash against science. The WEF identifies vaccines and immunization as subjects susceptible to disinformation and denial of scientific evidence.

Economic Risks

As monetary stimulus was kicked into high gear to prop up markets and support many closed businesses and quarantined families, the economic outlook seems more fragile than ever. Debt-to-GDP ratios continue to rise across advanced economies—if GDP growth stagnates for too long, a potential debt crisis could see many businesses and major nations default on their debt.

With greater stress accumulating on a range of major industries such as travel and hospitality, the economy risks a build-up of “zombie” firms that drag down overall productivity. Despite this, market valuations and asset prices continue to rise, with equity markets rewarding investors betting on a swift recovery so far.

Technological Risks

Last but not least, COVID-19 has raised the alert on various technological risks. Despite the accelerated shift towards remote work and digitalization of entire industries, the reality is that digital inequality leaves those with lower digital literacy behind—worsening existing inequalities.

Big Tech is also bloating even further, growing its digital power concentration. The market share some companies hold in their respective sectors, such as Amazon in online retail, threatens to erode the agency of other players.

Assessing the Top 10 Risks On the Horizon

Back in mid-2020, the WEF attempted to quantify the biggest risks over an 18-month period, with a prolonged economic recession emerging on top.

In this report’s risk assessment, global risks are further classified by how soon their resulting threats are expected to occur. Weapons of mass destruction remain the top risk, though on a much longer scale of up to 10 years in the future.

RankRisk%Time Horizon
#1🟠Weapons of mass destruction62.7Long-term (5-10 years)
#2🔴Infectious diseases58Short-term risks (0-2 years)
#3🔴Livelihood crises55.1Short-term risks (0-2 years)
#4🔵Asset bubble burst53.3Medium-term risks (3-5 years)
#5🟣 IT infrastructure breakdown53.3Medium-term risks (3-5 years)
#6🔵Price instability52.9Medium-term risks (3-5 years)
#7🟢Extreme weather events52.7Short-term risks (0-2 years)
#8🔵Commodity shocks52.7Medium-term risks (3-5 years)
#9🔵Debt crises52.3Medium-term risks (3-5 years)
#10🟠State collapse51.8Long-term (5-10 years)

Through this perspective, COVID-19 (and its variants) remains high in the next two years as the world scrambles to return to normal.

It’s also clear that more economic risks are taking center stage, from an asset bubble burst to price instability that could have a profound effect over the next five years.

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Visualizing Countries by Share of Earth’s Surface

There are 510 million km² of area on the Earth, but less than 30% of this is land. Here’s the share countries make up of the Earth’s surface.

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countries by share of earth's surface

Visualizing Countries by Share of Earth’s Surface

There are over 510 million square kilometers of area on the surface of Earth, but less than 30% of this is covered by land. The rest is water, in the form of vast oceans.

Today’s visualization uses data primarily from the United Nations Statistics Division (UNSD) to rank the world’s countries by their share of Earth’s surface.

Breakdown of Countries Share of Earth’s Surface

The largest countries by surface area are Russia (3.35%), Canada (1.96%), and China (1.88%).

Together they occupy roughly 7.2% of Earth’s surface. Russia is so big that even if we divided the country between its Asian and European sections, those new regions would still be the largest in their respective continents.

Country / DependencyTotal in km² (mi²)Percentage of Earth's Surface
Russia17,098,246 (6,601,670)3.352%
Antarctica14,000,000 (5,400,000)2.745%
Canada9,984,670 (3,855,100)1.958%
China9,596,961 (3,705,407)1.881%
United States9,525,067 (3,677,649)1.867%
Brazil8,515,767 (3,287,956)1.670%
Australia7,692,024 (2,969,907)1.508%
India3,287,263 (1,269,219)0.644%
Argentina2,780,400 (1,073,500)0.545%
Kazakhstan2,724,900 (1,052,100)0.534%
Algeria2,381,741 (919,595)0.467%
D.R. Congo2,344,858 (905,355)0.460%
Greenland (Denmark)2,166,086 (836,330)0.425%
Saudi Arabia2,149,690 (830,000)0.421%
Mexico1,964,375 (758,449)0.385%
Indonesia1,910,931 (737,815)0.375%
Sudan1,861,484 (718,723)0.365%
Libya1,759,540 (679,360)0.345%
Iran1,648,195 (636,372)0.323%
Mongolia1,564,110 (603,910)0.307%
Peru1,285,216 (496,225)0.252%
Chad1,284,000 (496,000)0.252%
Niger1,267,000 (489,000)0.248%
Angola1,246,700 (481,400)0.244%
Mali1,240,192 (478,841)0.243%
South Africa1,221,037 (471,445)0.239%
Colombia1,141,748 (440,831)0.224%
Ethiopia1,104,300 (426,400)0.216%
Bolivia1,098,581 (424,164)0.215%
Mauritania1,030,700 (398,000)0.202%
Egypt1,002,450 (387,050)0.197%
Tanzania945,087 (364,900)0.185%
Nigeria923,768 (356,669)0.181%
Venezuela916,445 (353,841)0.180%
Pakistan907,843 (350,520)0.178%
Namibia825,615 (318,772)0.162%
Mozambique801,590 (309,500)0.157%
Turkey783,562 (302,535)0.154%
Chile756,102 (291,933)0.148%
Zambia752,612 (290,585)0.148%
Myanmar676,578 (261,228)0.133%
Afghanistan652,230 (251,830)0.128%
South Sudan644,329 (248,777)0.126%
Somalia637,657 (246,201)0.125%
Central African Republic622,984 (240,535)0.122%
Ukraine603,500 (233,000)0.118%
Madagascar587,041 (226,658)0.115%
Botswana581,730 (224,610)0.114%
Kenya580,367 (224,081)0.114%
France543,940 (210,020)0.107%
Yemen527,968 (203,850)0.104%
Thailand513,120 (198,120)0.101%
Spain505,992 (195,365)0.099%
Turkmenistan488,100 (188,500)0.096%
Cameroon475,442 (183,569)0.093%
Papua New Guinea462,840 (178,700)0.091%
Sweden450,295 (173,860)0.088%
Uzbekistan447,400 (172,700)0.088%
Morocco446,550 (172,410)0.088%
Iraq438,317 (169,235)0.086%
Paraguay406,752 (157,048)0.080%
Zimbabwe390,757 (150,872)0.077%
Norway385,207 (148,729)0.076%
Japan377,976 (145,937)0.074%
Germany357,114 (137,882)0.070%
Republic of the Congo342,000 (132,000)0.067%
Finland338,424 (130,666)0.066%
Vietnam331,212 (127,882)0.065%
Malaysia330,803 (127,724)0.065%
Ivory Coast322,463 (124,504)0.063%
Poland312,696 (120,733)0.061%
Oman309,500 (119,500)0.061%
Italy301,339 (116,348)0.059%
Philippines300,000 (120,000)0.059%
Ecuador276,841 (106,889)0.054%
Burkina Faso274,222 (105,878)0.054%
New Zealand270,467 (104,428)0.053%
Gabon267,668 (103,347)0.052%
Guinea245,857 (94,926)0.048%
United Kingdom242,495 (93,628)0.048%
Uganda241,550 (93,260)0.047%
Ghana238,533 (92,098)0.047%
Romania238,397 (92,046)0.047%
Laos236,800 (91,400)0.046%
Guyana214,969 (83,000)0.042%
Belarus207,600 (80,200)0.041%
Kyrgyzstan199,951 (77,202)0.039%
Senegal196,722 (75,955)0.039%
Syria185,180 (71,500)0.036%
Cambodia181,035 (69,898)0.035%
Uruguay176,215 (68,037)0.035%
Somaliland176,120 (68,000)0.035%
Suriname163,820 (63,250)0.032%
Tunisia163,610 (63,170)0.032%
Bangladesh148,460 (57,320)0.029%
Nepal147,181 (56,827)0.029%
Tajikistan143,100 (55,300)0.028%
Greece131,957 (50,949)0.026%
Nicaragua130,373 (50,337)0.026%
North Korea120,540 (46,540)0.024%
Malawi118,484 (45,747)0.023%
Eritrea117,600 (45,400)0.023%
Benin114,763 (44,310)0.022%
Honduras112,492 (43,433)0.022%
Liberia111,369 (43,000)0.022%
Bulgaria111,002 (42,858)0.022%
Cuba109,884 (42,426)0.022%
Guatemala108,889 (42,042)0.021%
Iceland103,000 (40,000)0.020%
South Korea100,210 (38,690)0.020%
Hungary93,028 (35,918)0.018%
Portugal92,226 (35,609)0.018%
Jordan89,342 (34,495)0.018%
Serbia88,361 (34,116)0.017%
Azerbaijan86,600 (33,400)0.017%
Austria83,871 (32,383)0.016%
United Arab Emirates83,600 (32,300)0.016%
Czech Republic78,865 (30,450)0.015%
Panama75,417 (29,119)0.015%
Sierra Leone71,740 (27,700)0.014%
Ireland70,273 (27,133)0.014%
Georgia69,700 (26,900)0.014%
Sri Lanka65,610 (25,330)0.013%
Lithuania65,300 (25,200)0.013%
Latvia64,559 (24,926)0.013%
Togo56,785 (21,925)0.011%
Croatia56,594 (21,851)0.011%
Bosnia and Herzegovina51,209 (19,772)0.010%
Costa Rica51,100 (19,700)0.010%
Slovakia49,037 (18,933)0.010%
Dominican Republic48,671 (18,792)0.010%
Estonia45,227 (17,462)0.009%
Denmark43,094 (16,639)0.008%
Netherlands41,850 (16,160)0.008%
Switzerland41,284 (15,940)0.008%
Bhutan38,394 (14,824)0.008%
Taiwan36,193 (13,974)0.007%
Guinea-Bissau36,125 (13,948)0.007%
Moldova33,846 (13,068)0.007%
Belgium30,528 (11,787)0.006%
Lesotho30,355 (11,720)0.006%
Armenia29,743 (11,484)0.006%
Solomon Islands28,896 (11,157)0.006%
Albania28,748 (11,100)0.006%
Equatorial Guinea28,051 (10,831)0.005%
Burundi27,834 (10,747)0.005%
Haiti27,750 (10,710)0.005%
Rwanda26,338 (10,169)0.005%
North Macedonia25,713 (9,928)0.005%
Djibouti23,200 (9,000)0.005%
Belize22,966 (8,867)0.005%
El Salvador21,041 (8,124)0.004%
Israel20,770 (8,020)0.004%
Slovenia20,273 (7,827)0.004%
Fiji18,272 (7,055)0.004%
Kuwait17,818 (6,880)0.003%
Eswatini17,364 (6,704)0.003%
East Timor14,919 (5,760)0.003%
The Bahamas13,943 (5,383)0.003%
Montenegro13,812 (5,333)0.003%
Vanuatu12,189 (4,706)0.002%
Qatar11,586 (4,473)0.002%
The Gambia11,295 (4,361)0.002%
Jamaica10,991 (4,244)0.002%
Kosovo10,887 (4,203)0.002%
Lebanon10,452 (4,036)0.002%
Cyprus9,251 (3,572)0.002%
State of Palestine6,020 (2,320)0.001%
Brunei5,765 (2,226)0.001%
Trinidad and Tobago5,130 (1,980)0.001%
Cape Verde4,033 (1,557)0.001%
Samoa2,842 (1,097)0.001%
Luxembourg2,586 (998)0.001%
Mauritius2,040 (790)0.000%
Comoros1,862 (719)0.000%
São Tomé and Príncipe964 (372)0.000%
Kiribati811 (313)0.000%
Bahrain778 (300)0.000%
Dominica751 (290)0.000%
Tonga747 (288)0.000%
Singapore728 (281)0.000%
Federated States of Micronesia702 (271)0.000%
Saint Lucia616 (238)0.000%
Andorra468 (181)0.000%
Palau459 (177)0.000%
Seychelles452 (175)0.000%
Antigua and Barbuda442 (171)0.000%
Barbados430 (170)0.000%
Saint Vincent and the Grenadines389 (150)0.000%
Grenada344 (133)0.000%
Malta316 (122)0.000%
Maldives300 (120)0.000%
Saint Kitts and Nevis261 (101)0.000%
Marshall Islands181 (70)0.000%
Liechtenstein160 (62)0.000%
San Marino61 (24)0.000%
Tuvalu26 (10)0.000%
Nauru21 (8.1)0.000%
Monaco2.02 (0.78)0.000%
Vatican City0.49 (0.19)0.000%

Antarctica, although not a country, covers the second largest amount of land overall at 2.75%. Meanwhile, the other nations that surpass the 1% mark for surface area include the United States (1.87%), Brazil (1.67%), and Australia (1.51%).

The remaining 195 countries and regions below 1%, combined, account for the other half of Earth’s land surface. Among the world’s smallest countries are the island nations of the Caribbean and the South Pacific Ocean. However, the tiniest of the tiny are Vatican City and Monaco, which combine for a total area of just 2.51 km².

The remaining 70% of Earth’s surface is water: 27% territorial waters and 43% international waters or areas beyond national jurisdiction.

Areas Beyond National Jurisdiction

In the past, nations adhered to the freedom-of-the-seas doctrine, a 17th century principle that limited jurisdiction over the oceans to a narrow area along a nation’s coastline. The rest of the seas did not belong to any nation and were free for countries to travel and exploit.

This situation lasted into the 20th century, but by mid-century there was an effort to extend national claims as competition for offshore resources became increasingly fierce and ocean pollution became an issue.

In 1982, the United Nations adopted the Law of the Sea Convention which extended international law over the extra-territorial waters. The convention established freedom-of-navigation rights and set territorial sea boundaries 12 miles (19 km) offshore with exclusive economic zones up to 200 miles (322 km) offshore, extending a country’s influence over maritime resources.

Does Size Matter?

The size of countries is the outcome of politics, economics, history, and geography. Put simply, borders can change over time.

In 1946, there were 76 independent countries in the world, and today there are 195. There are forces that push together or pull apart landscapes over time. While physical geography plays a role in the identity of nations, Sheikh Zayed bin Sultan Al Nahyan, the former ruler of UAE, a tiny Gulf nation, put it best:

“A country is not measured by the size of its area on the map. A country is truly measured by its heritage and culture.”

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