By one estimate, it killed more Americans in 2016 than the entire Vietnam war.
The Centers for Disease Control calculates that 91 people die every day from opioid overdoses alone.
The awful toll keeps climbing.
Deaths from prescription opioids have quadrupled since 1999.
Cheap, easily available heroin is increasingly laced with deadly synthetic opiates like Fentanyl, a substance so powerful it can kill users before they’ve even finished injecting.
Some people’s muscles lock and they overdose while standing up, rigid and blue.
One outreach clinic nurse in New York once told me she had to pry a patient’s jaw open to administer CPR.
The director of New Hampshire’s state forensic lab showed me a vial with a few grains of white powder inside – enough to kill an adult male.
Heroin didn’t need any more help to be destructive.
In Ohio, parents are overdosing in cars with their toddlers strapped in the back seat.
In Vermont, the rate at which children are being removed from addicted families has sky rocketed.
Social workers there now routinely go on home visits with car seats already installed, in anticipation of what they will find.
A director at one drugs clinic in Washington Heights in New York told me that a few teenage school children have started dropping in to pick up clean syringes so they can use drugs before heading back to class.
In Kentucky, West Virginia, Pennsylvania, Tennessee, Florida and in so many more places, opioids are eating a hole in society.
People can’t work, they can’t contribute, can’t learn, pay taxes or look after children.
They start cycles of addiction in the lives of those around them, depriving families and friends of stability and opportunity, and a chance to advance.
Drug deaths now eclipse car crashes and gun violence, becoming the number one killer in the most powerful nation on earth.
Whatever Donald Trump labels it, the opioid epidemic has been a national emergency for some time.
But the complexity of the problem is confounding.
Poverty, failing families, poor education, lack of access to housing, health care and mental health care, over-prescription of pain medication, the power of pharmaceutical companies and the use of gateway drugs – all combine to form an impossible knot.
Addiction, said one crisis worker, is like the pick-up stick at the bottom of the pile.
So, marginalised, vulnerable people hide and harm themselves in the shadows, because their affliction is treated like a moral failure and not a disease.
What to do?
Stop the supply! Close the border! Lock up dealers and users! Punish pharmaceutical companies! Ban opiate prescriptions! Expend billions on an unprecedented public health drive! Focus on harm reduction! Legalise drugs!
The arguments are varied, loud and politically loaded, and anything approaching a solution continues to elude policy makers.
On Thursday, Donald Trump would declare the nation’s opioid crisis a public health emergency, senior administration officials said.
The President’s declaration will release funds, focus minds and possibly push Congress to make progress.
Many will rightly welcome a step in the right direction.
But those on the frontlines of the fight for survival and dignity that’s being waged in communities across America will also be worried that it is too little, and far, far too late.
Trump’s opioid ’emergency’ may be too little, way too late – Sky News