Drug overdoses now kill far more Marylanders and Americans than car crashes and homicides, and officials already know 2016 will be far worse than the year before.
There were 1,468 fatal overdoses statewide through September of this year, eclipsing the 1,259 deaths for all of 2015, Maryland's health department reported Thursday.
The number has more than doubled since 2010 in Maryland, one of about 30 states to report such a spike, and the data link those deaths to a group of drugs known as opioids.
Fatal overdoses rose for blacks and whites, men and women, young and old, and in every corner of the state.
"There has been a lot of stigma attached to what an addict is and who it affects," said Brad Masters, director of outreach for Serenity Acres Treatment Center in Crownsville. "The truth is that it affects everyone."
Public health experts trace the surge in overdose deaths to the overuse of prescription painkillers, the resurgence of heroin as an alternative and the rise of fentanyl, a highly potent synthetic opioid painkiller that sometimes is mixed with heroin, unbeknownst to the user. They also cited limited treatment options for addicts.
"There is no easy solution for this," said Dr. Leana S. Wen, Baltimore City health commissioner, who is pushing for widespread training in the use of naloxone, an opioid overdose antidote that is administered in a simple nasal spray and works instantaneously.
The city had by far the largest number of overdose fatalities in the state with 481 in the first nine months of 2016, and the largest jump from last year when there were 291 deaths in the same time period.
Big jumps were also reported in Anne Arundel County, which nearly doubled to 146 from 74, and Baltimore County, which jumped to 227 from 147. Harford County rose to 54 from 35, while Howard County increased to 32 from 20.
Deaths in nine more rural counties were smaller but doubled this year, while they went down or stayed the same in four others.
Wen said public health officials aren't even certain of the number of drug abusers in the city. The best government estimates are that there are about 21,000 Baltimoreans who use heroin. Officials don't know how many people abuse other types of opioids.
Dr. Sunil Khushalani, medical director of adult services at Sheppard Pratt Health System, which runs some treatment programs, said the medical community must rein in prescriptions of opioid painkillers, which can lead to dependence by consumers as well as friends or family members who may acquire leftover pills from the medicine cabinet.
Prescription drug use can lead to abuse of illicit opioids, like heroin, which are often cheaper and easier to get, Khushalani said.
The U.S. Centers for Disease Control and Prevention and others have issued guidance to doctors aimed at reducing the number of prescriptions. The U.S. Drug Enforcement Administration also has been cracking down on doctors and pharmacies that hand out opioids without prescriptions or demonstrated need.
Maryland recently became one of the last states to ramp up a prescription drug monitoring program, which allows doctors and pharmacists to see all prescriptions written for a patient.
Increasingly, however, overdose deaths in Maryland have been tied to fentanyl. More than 60 percent of the state's overdose deaths were linked to heroin in the first three quarters of the year and more than half were related to fentanyl.
Alcohol alone, meanwhile, accounted for just 2 percent of those deaths, while 28 percent were related to a combination of drugs and alcohol.
The DEA has reported difficulty in controlling fentanyl supplies that are often mailed from illicit labs operating overseas.
In Baltimore, Wen has formed a task force that immediately alerts drug treatment centers when someone has overdosed on fentanyl so they can warn the community about a "hot spot."
Many public health experts say insufficient treatment options as well as an unwillingness by some addicts to seek treatment contribute to rising overdose deaths.
Many addicts feel shame and the fear of being judged if they seek help, said Masters, who spent 60 days as a patient at Serenity Acres when he was 30 after realizing that he couldn't sleep through the night without going into withdrawal. The Centreville native was a successful salesman in his 20s but plunged into an prescription painkiller habit after his hard-drinking father committed suicide.
The stigma presents a significant barrier to getting care, Masters said, one that will only be overcome when the public accepts that addiction is a disease like cancer rather than a moral failing.
Yet there remains a shortage of treatment options, particularly "evidence-based" treatment, including ongoing counseling and support services such as housing, in addition to medication to curb cravings, those in the treatment community say.
Government and private insurance doesn't cover all treatment services, Masters and others say. For those paying out of pocket, or with high deductible insurance plans, a typical 30- to 60-day stay at Serenity Acres can exceed $24,000.
The state Medicaid program, for example, took one of the most common therapies, Suboxone strips, off its approved drug list for those on the state-federal health program for the poor in an effort to reduce smuggling into state-run correctional facilities. The thin strips meant to melt under the tongue contained buprenorphine, which interrupts the effect of opioids in the brain and are used to taper addiction.
Another barrier, treatment experts say, is that many places are not equipped to handle the other mental and physical health issues that often happen alongside addiction. Federal data show that up to 40 percent of people with an addiction also suffer a mental health problem.
Sheppard Pratt's Khushalani said he had a drug-using patient who suffered from bipolar disorder, post-traumatic stress disorder and three chronic medical conditions. When she stopped misusing prescription drugs, her PTSD symptoms would return.
Many facilities can't manage or treat the complex web of needs, even if insurance would cover a comprehensive recovery plan, Khushalani said, and patients often are left to navigate the health system themselves.
"Even if you just have one condition, navigating the health system can be quite hard," he said. "If you have multiple conditions, it makes it really challenging. Patients can knock on many wrong doors. ... We have to ask ourselves what kind of health care system do we have and is it the right system."
In Baltimore, officials don't know exactly how many treatment slots exist and how many people use them. Tallying them can be complex because some centers offer just medication or just counseling, and some offer a combination. Billing records, from Medicaid for example, can lead people to be counted twice if they visit more than one facility.
Wen said ideally the city would develop a real-time dashboard so officials could quickly steer people to treatment slots they know are available. Now, she said, officials hear anecdotal stories from people who want treatment and can't find it.
Until authorities get a handle on the problem, Wen has issued a blanket prescription for naloxone for anyone trained to use it, and state officials have followed suit. Wen said the drug has been used to save a life more than 530 times, according to reports from those administering the naloxone.
She acknowledges this is not a fix.
"We are still treading water unless we're able to get people into treatment at a time they need it," Wen said.
Wen pointed to actions that could help. The 21st Century Cures Act recently passed by Congress allocates $1 billion to drug treatment. Maryland could tap up to $10 million of the funds, said Kana Enomoto, deputy assistant secretary at the U.S. Substance Abuse and Mental Health Services Administration, during a recent community meeting called by the health department and focused on treatment access.
Federal health authorities also now allow doctors who prescribe Suboxone or other buprenorphine medications for opioid dependence to treat 275 patients at a time, up from 100. State officials recently launched a drug screening program and signed an agreement allowing Medicaid recipients to use their federal-state health benefits to pay for residential drug treatment beginning in 2017.
Wen hopes all the measures will help decrease overdose deaths.
A landmark U.S. Surgeon General report released this month predicted that one in seven people can expect to develop a substance abuse problem in their lifetime. Only 10 percent could now expect treatment.
"If this were Ebola or a new kind of cancer," Wen said, "we'd absolutely be demanding resources to fight this disease that is claiming so many lives."