The cost of the nation’s opioid crisis exceeded $1 trillion from 2001 to 2017, a new report concludes. The epidemic may cost an additional $500 billion by 2020.

The findings come from Altarum, a nonprofit health research and consulting institute. The greatest cost of the opioid crisis comes from lost earnings and productivity losses to employers, NPR reports. Other costs come from lost tax revenue due to early deaths and substance use disorders.

Emergency room visits, ambulance costs and the use of naloxone also have contributed to the increase in costs, the report notes.

Opioid-related expenses are rising in part because more young people are being affected. “The average age at which opioid deaths are occurring — you’re looking at something in the late 30s or early 40s,” said Corey Rhyan, a senior research analyst with Altarum’s Center for Value and Health Care. “As a result, you’re looking at people that are in the prime of the productive years of their lives.”