Most is coming not from across the southern border but from unregulated pharmaceutical companies in China.
For Ryan Lay, August 16, 2016, began like any other day. The seventeen-year veteran Cincinnati police officer showed up for second shift at 1 P.M., swapped a few jokes with fellow officers, and was quickly dispatched to his first call—a drug overdose.
Officer Lay pulled up to a two-family home, where he found a white male in his late thirties unconscious in a garage. The man, whom Lay knew, was an employee of Home Depot who had recently started buying street heroin after a long addiction to prescription painkillers.
Overdoses were not uncommon in police District Three, one of Cincinnati’s low-income housing areas. Officer Lay typically responded to two or three such calls a week. Most weren’t fatal and he was often able to revive overdose victims with naloxone, a medication that reverses the effects of opioids, such as heroin.
Lay sprayed a dose of naloxone up the man’s nose. After another first responder administered a second dose, the man woke up. But before Lay was able to see the man safely transported to the hospital, he was already on his way to a second call—also a drug overdose.
After this call, I need to head back to the station and stock up on more naloxone, he thought.
But Lay never made it back to the station. After the second overdose incident, he was called out to another. Then another. Then another. By the time his shift ended, Lay had responded to thirteen overdoses. Other officers in his district were experiencing the same thing.
“It was overwhelming,” Lay relates in a phone interview. “The calls for service for overdoses put everything else on hold. [We] didn’t know what to do. It happened so fast.”
Officer Lay pulled up to a two-family home, where he found a white male in his late thirties unconscious in a garage.
The officers had no idea what was causing all the overdoses. Something had happened to the heroin supply. Autopsies at the medical examiner’s office would soon provide the answer: Fentanyl had come to Cincinnati.
Fentanyl is a synthetic opioid that is more than fifty times as potent as heroin. It was first synthesized in 1959 to relieve pain in surgery and for cancer patients. Medical providers typically administer it via injection or by prescribing a transdermal patch that allows the drug to be slowly absorbed into the bloodstream.
But, beginning in 2014, large quantities of illicit fentanyl, in the form of a white powder, began arriving in the United States from China.
China’s chemical and pharmaceutical industry is vast and largely unregulated, so it’s not difficult for any of the country’s estimated 160,000 licensed and unlicensed chemical companies to create fentanyl from synthetics that mimic the effects of opium. Synthetic opioids are easier to manufacture than natural opiates derived from poppy plants, such as heroin, and more lucrative. Customers around the world can easily purchase fentanyl over the Internet and request a shipment for personal use or to sell.
Today, almost half of the illicit opioids in the United States are laced with fentanyl, an estimated 80 percent of which arrives in the mail from China. Some of the rest comes across the southern border, primarily smuggled in vehicles through legal ports of entry.
Because fentanyl is inexpensive to make and highly potent, it is often mixed into other illicit drugs. People buying or selling the drugs may not even know whether the product contains fentanyl or how strong it is.
William Miller Sr., a sixty-four-year-old resident of Baltimore, Maryland, and a longtime heroin user, recalls the sudden arrival of fentanyl in the drug supply in his community around 2015.
“I knew something was different about the drug, but I didn’t know fentanyl had been added,” he says. “That warm feeling you get with straight heroin—you don’t get that with fentanyl. Fentanyl brings you down.”
He also noticed a spike in overdoses, even among people who snort their drugs, which typically doesn’t cause a severe reaction. Baltimore and Cincinnati weren’t the only cities with a problem. Nationally, deaths involving fentanyl have doubled every year since 2014. In 2017, synthetic opioids (almost all fentanyl) were associated with more than 28,000 deaths, higher than for any other opioid. Recent victims have included musicians Tom Petty and Prince.
Miller notes that when fentanyl first hit the market, many drug users didn’t want to buy it. They didn’t like the high or the added risk of overdose. But then they didn’t have much choice. In a short time, fentanyl was everywhere, even mixed into such nonopioid drugs as cocaine and methamphetamine. It was also cheap. Miller says he used to pay $10 for a capsule of heroin, whereas an equivalent dose of fentanyl costs $6.
Low prices and the lure of a stronger high have led many people who initially disliked fentanyl to develop a taste for it. Miller “would rather have the heroin high,” but says many users he knows have come to prefer fentanyl over other drugs.
In fact, many users now use fentanyl test strips to check the drugs they take for the presence of fentanyl. They may also carry naloxone and try to use drugs only when others are present, in case of overdose.
Fentanyl has also stirred up fear among first responders, as rumors have spread about the drug being deadly to the touch. Several unsubstantiated reports of police officers overdosing from contact with airborne fentanyl have gone viral, and Massachusetts even banned evidence containing fentanyl from courthouses. But the medical and scientific communities have determined that this fear is mostly unfounded.
Tom Synan, chief of police for Newtown, Ohio, says that through “more data and research, we know that the chance is extremely low for a first responder to overdose from inhaling [fentanyl] or just touching it.” He asks his officers to use basic precautions, such as wearing gloves and washing their hands if they accidentally get fentanyl on their skin.
Synan leads the Hamilton County Heroin Coalition, a task force of more than three dozen agencies in the Cincinnati area that are working to respond to opioid-related deaths. He credits the emergency that fentanyl has created with sparking discussion about better ways to approach drug policy, including among law enforcement officers.
“There are police officers saying what we have done in the past hasn’t worked,” Synan says. “A lot of times we weigh [sentencing] decisions by the weight of the drug and now we are looking at the intent of the seller. Fentanyl has shifted the discussion. It’s more in the open. Maybe we should have done this fifty years ago, but if it were not for fentanyl and the numbers of people dying, we probably would not have shifted.”
Concern over fentanyl-related deaths has spurred a nationwide search for solutions. Some people are calling for greater access to drug treatment, wider availability of naloxone, and criminal justice diversion programs that link offenders to social services. Others are clamoring for governments to regulate doctors, sue the pharmaceutical industry for peddling addictive prescriptions, and create an army of mental health professionals to tackle the problem.
Some people are calling for greater access to drug, others are pushing for harsher crackdowns on drug dealers, long prison sentences, and a wall.
“Our southern border is a pipeline for vast quantities of illegal drugs including meth, heroin, cocaine, and fentanyl,” Trump declared in a prime-time address to the nation in January. But the President’s own Commission on Combating Drug Addiction and the Opioid Crisis disagrees, as its 2017 report did not include recommendations for a border wall. Although some fentanyl enters the United States from Mexico, more than three-quarters of the fentanyl smuggled through Mexico crosses at the San Diego port of entry, not through open border land.
In fact, efforts to shut down the drug supply through aggressive enforcement often cause the market to morph into something even more deadly.
According to popular lore, the opioid crisis began during the 1990s when doctors, lured by kickbacks and incentives from predatory pharmaceutical companies, started overprescribing opioids to innocent patients, who then became hooked. Efforts to curb overprescribing led doctors to stop writing prescriptions, leading patients to turn to street heroin to support active addictions. Later, as tolerance for heroin increased, they started seeking a stronger drug, fentanyl.
But a number of other public health researchers, including Leo Beletsky, associate professor of law and health sciences at Northeastern University, say this narrative is misleading.
“I think this crisis is an illustration of how we respond to public policy issues where we create narratives that are simple and intuitive,” Beletsky says. “In drug policy, the narrative is always around a particular drug: meth, crack, opioids. That narrative involves a hero and a villain.”
Beletsky explains that during the crack scare of the 1980s, the public cast criminal cartels and so-called superpredators of minority races as the bad guys pushing drugs on innocents. Now, he says, we “start seeing that narrative applied to corporations. It’s a melding of populism and anti-corporate ethos that is pervasive on the left and right . . . Drug companies are an easy villain.”
The reality, he says, is far more complicated. Though it is true that pharmaceutical companies began marketing opioids aggressively in the 1990s and that many of these drugs are potentially addictive, the narrative of the unsuspecting pain patients who became hopelessly hooked through no fault of their own is largely false.
Most people who develop a substance-use disorder misused prescriptions by taking more than directed or by mixing them with other drugs. In fact, it is rare for someone to overdose on one substance alone—even something as potent as fentanyl. The vast majority of overdose deaths involve more than one drug.
Medically prescribed fentanyl has been utilized as an effective pain reliever for decades in the United States. One review of studies of addiction rates among chronic pain patients found that fewer than 8 percent of patients prescribed opioids become addicted. By way of comparison, the 2016 National Survey on Drug Use and Health numbers indicate that 11 percent of alcohol drinkers age twelve and older have developed alcohol-use disorder.
The problem with illicit fentanyl is that many people don’t know the strength or content of what they are using. The lack of information that is inherent in an unregulated drug supply can create the perfect storm for an overdose epidemic.
There is a close historical parallelto the current situation involving fentanyl abuse.
During the 1920s, when the sale of alcoholic beverages was briefly outlawed in the United States and bootleggers began peddling unregulated liquor, alcohol poisoning deaths quadrupled within five years. Additionally, during this period, almost 90 percent of American consumers, who had preferred beer and wine before Prohibition, switched to drinking hard liquor.
The transition from weaker substances to more potent ones in an illicit market is a phenomenon known as the Iron Law of Prohibition. Most economic markets are driven by consumer demand, but illicit markets are often driven by supply. Comparatively weak, heavy substances such as beer or heroin are difficult to transport and conceal from law enforcement, so illicit dealers market lighter, more potent substances that are easily hidden.
“When you are smuggling something through the border or transporting it domestically, it makes more economic sense to make and transport fentanyl because you are getting more bang for your buck,” Beletsky explains.
That is why enforcement efforts rarely lead to a sustained reduction in drug supply. Illicit suppliers merely switch their products to something lighter and stronger—often with deadly consequences for consumers.
So how can we respond to the threat of fentanyl, which is significantly adulterating the drug supply and contributing to many deaths?
Beletsky and other public health officials maintain that the answer is to stop focusing on what people are using and to start focusing on why.
“People are in a lot of pain,” says Beletsky. “People are hurting economically. People are hurting emotionally. People are stressed. People are physically unwell. When opioids came on the scene they became very popular because it doesn’t matter what is wrong with you. Opioids will make you feel better.”
A strong statistical link exists between poverty, high unemployment, and opioid-related hospitalizations and deaths. Across the United States, overdose deaths are most pronounced in areas with a history of low participation in the labor force, stagnated marriage rates, and high levels of poor physical and mental health.
Researchers are beginning to pick up on the relationship between poor quality of life and opioid misuse. British journalist Johann Hari, who has spent his career investigating the underlying social and economic conditions that often precipitate drug addiction, says the systems currently in place to address the drug crisis are designed for quick, superficial fixes. Doctors see patients for a few minutes and send them off with prescriptions. Jails lock people up for a short time and then dump them back out on the streets. Insurance companies rarely pay for more than twenty-eight days of drug treatment, even for patients who have struggled with addiction for years.
But Hari sees hope in an emerging trend toward integrating medicine with other systems of care. As of 2018, more than 300 collaborative arrangements, called medical-legal partnerships, operate in the United States to provide legal aid, access to health insurance and public benefits, housing support, employment assistance, and help with personal or family issues to patients seeking medical care.
Hari notes the difficulty of shifting toward holistic thinking about pain and addiction, because “we don’t value the lives of the people who are dying as much as we value our dogmas, our ideologies, and our prison-industrial complex.” But he’s optimistic that it could yet occur. He suggests starting with a simple change: Instead of asking people who use drugs, “What is the matter with you?” we should ask, “What matters to you?”
Fentanyl may be the crisis to spark that switch.
How Fentanyl Gets into the United States
Fentanyl is unique among illicit drugs, not only for its potency, but also for the way in which it enters the United States.
Unlike most illicit substances, which are either manufactured in the United States or smuggled across the southern border, most fentanyl is shipped directly to customers by mail (usually from China). In fact, according to a January 2018 report to the U.S. Senate, fentanyl is readily available for sale on the open Internet and through the “dark web” (a collection of online sites that hide their IP addresses so their locations can’t be searched).
One seller, the report said, was selling two grams of powdered fentanyl for $145 with guaranteed arrival, or a $78 purchase that carries the risk of being seized by U.S. Customs and Border Patrol, the agency that monitors international packages. Fentanyl can also be pressed into pill form and sold by the tablet.
Illicit fentanyl has sprung from China’s vast, under regulated pharmaceutical industry. Until 2017, China had no ban on the manufacturing of fentanyl and any enterprising chemist could create the drug for shipment to U.S. customers.
Two years ago, under pressure from the United States, China banned the illicit manufacture of fentanyl. Many chemists got around the ban by creating new formulations of the drug. According to the United Nations Office on Drugs and Crime, more than a dozen fentanyl analogues exist on the market.
In May, China added fentanyl to its list of controlled substances, which effectively bans all formulations of the drug and subjects violators who export fentanyl to the death penalty. China has a long history of executing drug offenders. President Trump praised the move, declaring it “a game changer on what is considered to be the worst and most dangerous, addictive, and deadly substance of them all.”
However, China has little infrastructure in place to enforce the fentanyl ban, and there is widespread corruption among enforcement agencies. It remains to be seen whether the country’s recent actions to appease the United States will do anything to stanch the export of fentanyl.