Study: Crackdowns on Heroin, Pain Pills Gave Rise to Fentanyl Overdose Epidemic [FEATURE]

A new report on illicit US drug markets from researchers at the University of San Francisco has found that that the spread of fentanyl, a powerful synthetic opioid implicated in nearly 29,000 overdose deaths last year alone, is tied to enforcement-driven shortages of heroin and prescription opioids, as well simple economics for drug distributors -- not because users particularly desire the drug.

meet the law of unintended consequences (Creative Commons)
Illicit fentanyl has swept through American drug markets in waves -- the super strong "China white" heroin of the 1970s was actually a heroin-fentanyl mixture -- most recently in the past decade after rising levels of opioid addiction and the spread of "pill mills" prompted multifaceted moves to restrict opioid prescribing.

From a drug distributor's perspective, fentanyl is a most excellent substitute for heroin or prescription pain pills. Produced entirely in labs or chemical factories, it is far more powerful and cheaper to produce than heroin. Because it's more potent, it is easier to smuggle -- often coming into the US via postal and delivery service parcels, not by the semi load. And it doesn't require months of growing time and period of intense peasant labor in lawless regions of weak states.

Fentanyl is typically sold deceptively -- marketed as heroin or prescription drugs such as OxyContin or Xanax -- and users and street-level dealers often don't even know that the drugs they are using or selling contain fentanyl, the researchers found. Fentanyl is making its way into the supply chain at the wholesale, not the retail level. That, the researchers said, suggests that demand is not the key driver in the drug's spread.

"Fentanyl is rarely sold as fentanyl," said Sarah Mars, PhD, a researcher in the Department of Family and Community Medicine at UCSF. "The dealers selling fentanyl directly to the users often don't know what's in it. Not only is this particularly dangerous, but it also means penalizing low-level dealers isn't going to make any difference in the fentanyl poisoning epidemic."

According to Mars, users are split on fentanyl, which produces a more sudden and powerful high than heroin, but one that fades faster. Some said fentanyl brought back the euphoria they had lost the ability to feel with long-term heroin use, but others said they feared fentanyl and found its effects too harsh.

"Whether or not they prefer fentanyl, users don't have any influence over what drugs are being sold," Mars said. "Without accurate information about these drugs, they can't make an informed choice about what they are buying. Also, very little drug slang has developed to describe fentanyl, which lends support to the notion that this is not a demand-driven epidemic."

The presence of drugs adulterated with fentanyl is uneven, Mars said.

"Most of the illicit fentanyl has been in the Northeast and Midwest," she specified. And that's where opioid overdose death rates are the highest.

Another contributing factor to the fentanyl overdose toll is that it has dozens of analogs with wildly varying potency. Some, like carfentanil, are amazingly powerful, as much as 10,000 times as potent as morphine. Some are so new they have not yet been made illegal.

"We believe it's the fluctuation in the potency of the drugs containing fentanyl that makes them so dangerous," said Daniel Ciccarone, MD, MPH, a professor of family and community medicine at UCSF and senior author of an ongoing National Institutes of Health-funded study, Heroin in Transition. "You might have one dose that had hardly any fentanyl in it or none at all. Then, you might have one with a different fentanyl analog, of different potency, or even mixtures of multiple fentanyls and heroin."

Here is the paradox of drug prohibition: Trying to crack down on drugs tends to lead not to less drug use but to more dangerous drugs, and in the case of opioids, tens of thousands of dead drug users. There is an inexorable logic at play: The more law enforcement comes down on a drug, the greater the tendency for suppliers to make it more potent and compact -- and dangerous.

Perhaps that's why we now see mainstream calls for a radically different approach, such as the one from Washington Post columnist Megan McArdle earlier this week. In her column "The Incredibly Unpopular Idea That Could Stem Heroin Deaths," McArdle argues that current drug policy is only running up the overdose death toll and that we need "to start talking about ways to make safe, reliable doses of opiates available to addicts who aren't ready to stop."

That would involve increasing access to opioid substitutes such as methadone and buprenorphine, "but lowering the death toll may require a more drastic step: legalizing prescriptions of stronger opiates," McArdle writes.

"Prescription heroin?" she continues. "Remember, I said you might not like the solution. I don't like it, either -- and frankly, neither do the drug policy researchers who told me it may be necessary. But when fentanyl took over the US illicit drug markets, it also got a lot of addicts as hostages. We'll never be able to rescue them unless we can first keep them alive long enough to be saved."

There is a better way to deal with the opioid crisis than relegating tens of thousands of American opioid users to early, preventable deaths. We know what it is. Now it's a matter of implementing smarter, more humane policies, and that's an ongoing political struggle -- one where lives are literally at stake.

Permission to Reprint: This article is licensed under a modified Creative Commons Attribution license.
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As I said

In Feb of 2014,the government of BC,Canada instituted a monopoly or Mallencrodt and it's inferior product,Methadose.At the exact same time heroin vanished from Vancouver streets and was replaced by Fentanyl.Dealers,when asked,said it :"gotthejobdone".Meaning you don't feel anything but the sick goes away.Great deal.For the gangsters.For addicts,it was a step away from theft.The RCMP/CSIS working together had eliminated chinese heroin from Vancouver.After many decades of a steady supply.The police might as well have just lined everyone up and shot them in the head.They had already eliminated every healthy cut and other products that had been a tradition in Vancouver for decades.They eliminated all but a few pay phones.Those they monitored 24/7.Methadose is 5X weaker than the original L isomer methadone.It is D isomer.Cheaper to make and inferior in every way.No addict would leave the streets for Methadose.It doesn't replace heroin.It may replace Fentanyl?You'd have to drink 5X the prescribed dose if it did.This is why there were deaths when the switch came.Deaths hidden by the BC Lieberals.How Fentanyl replaced heroin at the exact same time is a mystery.There were several large shipments of #3 chinese heroin seized by police at the airport.Fentanyl is available for a tiny fraction of the cost of heroin.It has zero euphoria.It's used by people already addicted.The Vancouver scene is set up to maintain people's drug habits.Deaths by Fentanyl OD are still at unconscionable levels.Hydromorphone is available from someone on the DTES.In what dosages I have no idea.What's needed is a safe,clean supply of good chinese heroin.Handed out to addicts who are registered with BC health.Either for cost,or for free to those who can't afford it.No restrictions.

Fentanyl Overdoses

If it were not for 105 years of Drug Prohibition driving drug use underground, the USA would have developed safe and socially-acceptable ways to use opiates.  Countries from the Pacific Rim to Turkey have smoked opium for centuries with few if any overdose cases.  That is because the user will pass out before inhaling a lethal dose of the natural opiate.  Safety built in to the process!  What a concept!  More dangerous methods such as intravenous injection of heroin or opioid substitution with super-potent fentanyl would probably be quite rare.  

Drug prohibitionists take note:  The Road to Hell is Paved with Good Intentions...

Doctor Jim

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