Fentanyl is the Problem but Interdiction is not the Answer

​After some brief victories, the opioid epidemic has roared back like a lion.  Overdose deaths, more than 400,000 since 1999, briefly dropped due to better control of prescription medication.  Users diverted their purchases to illegal drugs, often loaded with fentanyl to enhance potency, and mortuaries and graveyards are crowded with the results.  The United States has countered with old school interdiction efforts, but these methods have never worked, and a new strategy is required to manage this scourge.

Enough Fentanyl to Cause an Overdose (United States Drug Enforcement Administration)

Fentanyl, a synthetic opioid pain reliever, formally approved for treating severe pain, is up to 100 times more potent than morphine and is usually delivered via transdermal patches or lozenges.  Most recent cases of fentanyl overdose and death in the United States are linked to fentanyl sold through illegal drug markets and used to ‘spike up’ heroin leading to a potent mix; potent enough to stop hearts and lungs and fill mortuaries and graveyards with overdose victims.

​In 2018, drug overdose deaths declined for the first time since 1990.  The decline was almost entirely due to a reduction in deaths from prescription opioid painkillers as the management of prescriptions was the simplest and fastest way to impact the problem.  High-profile prosecutions of drug companies raised alarms as to potential liabilities and the sales and distribution network throttled back on these drugs.  Although no empirical data exists it is likely addicts diverted to illegal drug distributors, leading to the spike in overdose deaths.  

​Interesting facts:

• The rate of overdose deaths involving synthetic opioids (other than methadone) increased 10% from 2017 to 2018. 
• Over 31,000 people died from overdoses involving synthetic opioids (other than methadone) in 2018 and 37,000 in 2019. 
• Synthetic opioids, including fentanyl and fentanyl analogs, killed more Americans in the past 12 months than any other type of opioid.
  
• In 2019, over 70,000 drug overdose deaths occurred in the United States, and deaths involving synthetic opioids (other than methadone) continued to rise with more than 36,000 overdose deaths reported in 2019.
• In 2018 about 10 million people aged 12 or older misused opioids in the past year.  About 9.9 million people misused prescription pain relievers about 800,000 people used heroin.
• Drug overdose deaths involving heroin rose from about 2,000 in 1999 to about 16,000 in 2016.  Since 2016, the number of deaths has trended down with about 14,000 reported in 2019.
• National statistics trail by as much as a year but regional information indicates opioid-related deaths jumped in 2020.

​China has a vast pharmaceutical and chemical manufacturing capacity, making compounds sold globally for medical and industrial processes. International pressure compelled China to ban the production and sale of fentanyl and many of its variants in May 2019, resulting in a significant reduction in the country's licit fentanyl trade.  Chinese vendors still sell and ship fentanyl, analogs, and the precursor chemicals used to make fentanyl, illegally, to customers all over the world, but primarily to the United States and Mexico.  Due to the potency, thousands of doses can be shipped in small packages using ‘stealth’ packaging making interception incredibly difficult.

​The impact of opioids is immense as they cost the United States economy about $630 billion from 2015 to 2018.  Mortality costs accounted for 40% of the assessed financial effect, mainly because of lost lifetime earnings for those who died prematurely due to drug overdoses involving opioids.  Other costs:

• Health care spending for individuals with opioid use disorder.
• Criminal justice costs.
• Costs associated with government-funded child and family assistance programs and education programs.
• Lost productivity costs.  

Interdiction Makes for Splashy Photos as in this US Coast Guard Marijuana Seizure

America’s management of drugs has followed a standard pattern of criminalizing drug use and distribution combined with interdiction of shipments, with prison sentences.  Cloaked with terms such as ‘war on drugs’ these efforts have been spectacular failures.  Histories of criminalization and interdiction of substances in the United States have been failures, including:

• Prohibition of alcohol.
• Marijuana.
• Cocaine.

Interdiction with opioids becomes even more problematic due to the small size of shipments – rather than cramming a ship with marijuana this is transported to distributors via common carrier concealed in small airtight packages.  Interdiction may have a role in the management of the problem but relying on such measures as a primary method ensures the problem will never be solved.

Treatment for opioid use disorders includes medication-assisted treatment (MAT), which includes a variety of opioid surrogates such as methadone, buprenorphine, and naltrexone, used to reduce cravings and allow the patient to resume some sort of normal life.  These treatments are typically used to manage patients identified by the criminal justice system and are administered at community-based clinics.  These are combined with 12-step programs, counseling, and therapy to provide some support for addiction management.

Drug addiction treatment has been shown to have remarkable cost-benefit advantages.  Treatment is also much less expensive than incarcerating addicted persons.  The average cost for one year of methadone maintenance treatment is about $4,700 per patient, whereas imprisonment costs about $24,000 per person.  The ideal patient contributes then to society through some form of work rather than being a burden although there are a variety of outcomes.  Every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft.  When savings related to healthcare are included, total savings can reach a ratio of 12 to 1.

​Authoritative empirical data on the effectiveness of various treatment regimes for his disorder is difficult to find.  The lack of data allows continued churn in methodologies but it is clear there is no ‘magic bullet’ for treatment, rather a variety of ways of management, similar in concept to managing other chronic health problems such as diabetes or heart disease.

The existing data on opioid addiction management offers some conclusions:

• The definition of success is a fundamental problem as there are a variety of definitions used in the medical-industrial complex.
• Successful addiction treatment requires continual evaluation and modification and intellectual framework as a chronic condition.
• For both residential or outpatient treatment length of intensive treatment is correlated with positive outcomes.
• Relapse is expected and multiple episodes are required before ‘recovery.’
• For methadone maintenance, 12 months is considered the minimum, and some opioid-addicted individuals continue methadone maintenance for many years.

​This investigation provokes several observations:

• Research into the efficacy of treatment regimens is a necessary step to inform future endeavors.
• Interdiction and criminality are systems that continue to fail in the United States and only seem to provide additional burdens to society.
• Decriminalization of opioids and community-based management would greatly reduce overdose potential.
• Decriminalization of marijuana in various states has been successful and arguably could offer benefits in the opioid arena.
• Multiple agencies manage the opioid epidemic reaction and it seems leadership and consistency would help in better outcomes.
• Accurate and timely reporting of deaths is lacking and would be helpful in responses.

​Basic information about fentanyl was provided by https://www.cdc.gov/drugoverdose/opioids/fentanyl.html.  The United States Congress report can be found at https://crsreports.congress.gov/search/#/0?termsToSearch=opioid&orderBy=Date.  Information about federal funding was discovered at https://www.budget.senate.gov/imo/media/doc/SBC%20Trump%20Budget%20Opioid%20Epidemic%20Fact%20Sheet%202-25-20%20FINAL.pdf and https://www.hhs.gov/sites/default/files/fy-2021-budget-in-brief.pdf.  Data on positive developments in the opioid epidemic was obtained at https://www.hhs.gov/opioids/about-the-epidemic/opioid-crisis-statistics/index.html.  Opioid treatment economic arguments were provided by https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/how-can-family-friends-make-difference-in-life-someone.