The drug problem is going to get worse before it gets even worse

You may have read of the drug bust that found enough fentanyl to kill 26 million people That is a massive number so I was shocked to lead that the total haul was just 118 pounds, which works out to about two milligrams per fatality. Mark Kleiman explains that fentanyl is one of the most potent drugs, which is why a tiny amount can be so dangerous. He says that fentanyl is just one of a class of synthetic opioids that are far more dangerous than prescription opioids and heroin and also much easier to produce since they do not require an agricultural crop as its starting point but can be made entirely in a lab.

First, a little bit of chemistry and pharmacology. “Fentanyl,” in its precise use, is the name of a single molecule. It’s a purely synthetic opioid: that is, it binds to the same μ opioid receptors as oxycodone or heroin does and has most of the same effects, but it’s not made from the opium produced by the poppy plant; its raw materials are chemicals, not crops. It’s about thirty times as “potent” as morphine: that is it takes about thirty times as much morphine as it does fentanyl to get the same pain relief.

But the “parent” fentanyl compound turns out to be one member of a very large chemical family, known generically as “fentanyls,” each with its own name and a varying set of pharmacological properties. Some of them are astoundingly potent: carfentanil, for example, has something like 100 times the potency of fentanyl itself, which makes the effective dose for a human a fraction of a microgram.

He says that these drugs have a very narrow ‘therapeutic window’, which is the difference between the median effective dose and the median lethal dose, which is why it is so easy to overdose and die. And since the doses are so small, it is hard to split and thus easy to make a mistake.

To make things even worse, neither users nor dealers have reliable ways of knowing just what’s in the white powder they’re consuming or selling: someone who injects what he thinks is the right dose of heroin, but has in fact purchased fentanyl, is likely to stop breathing. Even someone who intends to take fentanyl could die if he’s actually been given, say, 3-methylfentanil or some other high-potency analogue.

Kleiman says that after authorities started cracking down on prescription opioid abuse, people shifted to heroin because the price of that drug had dropped dramatically. And fentanyl was the next logical step because its high potency and the fact that it could be easily produced synthetically and required such tiny amounts made it highly attractive to dealers and producers.

Instead of using complicated smuggling schemes, sellers simply put these products in the mail; for about $20, you can get a package of up to four pounds mailed from China to New York.

It didn’t take long for some of those Chinese outfits to start making fentanyl; unlike heroin dealers, they didn’t need a source of opium. The chemistry involved isn’t especially challenging (not, for example, like making LSD). Fifty grams of fentanyl – an ounce and a half – has the potency of a kilogram of heroin, and it’s way, way cheaper.

For law enforcement, the parcel-post approach makes a hard problem nearly impossible. The volume of legitimate parcel post from China to the U.S. means that there’s no way to scan every package, or even a high enough fraction to make the traffic uneconomic. As more and more potent molecules appear, I’d expect another shift, from parcel post to regular international mail, moving the drugs in quantities of a gram or less, perhaps dissolving them, soaking a sheet of ordinary paper in the solution, typing a letter on the paper, mailing it, and then extracting the drug at the other end of the process.

So that’s why the fentanyls are a big factor now when they weren’t before. And I don’t see a snowball’s chance in Hell of stopping the flow. It’s possible that, with adequate urging from the U.S., the Chinese authorities might succeed in cracking down on illicit manufacture and sale. But there’s nothing magical about China. India also has skilled chemists and a huge flow of mail to the U.S. So, for that matter, does Canada. And so does the U.S.; if international sources dry up, the stuff will be made here.

From the retailer’s point of view, [the old style of street dealing of drugs] meant exposure to both enforcement risk and the risk of robbery. It also greatly decreased the number of transactions a dealer could consummate in an hour, since most of his time was spent waiting for customers to arrive. Much of the retail price of illicit drugs represented compensation to the retail dealer for those risks and costs.

But with mobile phones, texting, and social media, transactions can now be arranged electronically and completed by home delivery, reducing the buyer’s risk and travel time to near zero and even his waiting time to minimal levels. In the recent Global Survey on Drugs, cocaine users around the world reported, that their most recent cocaine order was delivered in less time, on average, than their most recent pizza order.

Kleiman’s article alarmed me more than any other article I have read on the drug problem because we seem to be headed for a drug nightmare. The supply side of the equation seems to limitless and unstoppable. The demand side will have to be the place where we can hope to limit the damage, not by indiscriminately locking up users, but by helping people wean themselves from dependency. As a start, we may need to make the antidote drug naloxone as widely available as possible to at least stem the number of deaths from overdoses.


  1. Pierce R. Butler says

    Every innovation in illicit drugs gets heralded by “Panic! NOW!!1!” news stories.

    When has the ensuing reality ever come close to the hype?

  2. cartomancer says

    The real solution to tackling the drug problem lies in tackling the social and economic circumstances that lead people into addiction in the first place. Which is, naturally, much more wide-ranging in scope than just providing rehab and emergency treatment (though those are necessary too, particularly in the immediate future).

    The USA is failing hard here on two fronts. First of all its abysmal lack of provision for the welfare of the poorest and most vulnerable. Particularly healthcare provision -- those people who cannot afford medical care will inevitably turn to illegal painkillers for their needs. Secondly its medical culture of having drug companies pay doctors to prescribe as many drugs as possible. The latter is a big driver of the problem in the US, since opiate-based medicines are massively over-prescribed, and when this creates addicts those addicts often turn to illegal dealers when their prescribed supply runs out. And, of course, the decision to keep all recreational drug use strictly illegal prevents anything by way of meaningful quality control checks.

  3. says

    The government ought to offer clinical pain relief. Instead of trying to stop it, make it safe. The reason there is a crisis is because doctors were handing out oxy like it was candy, and then they stopped once a lot of people were dependent on opiates. So naturally people started buying the synthetics. Thank big pharma and the doctors.

  4. jazzlet says

    It would also help if we could measure pain, at the moment doctors have to use their judgement as to whether a patient is really in pain and how much pain at that, having an objective way to know would help everyone. People who really are in pain woud get the relief they need, people who aren’t in physical pain, but who want to block out the life they are living could be given appropriate help. Well I can dream.

  5. says

    I fear you are correct, especially about making Naloxone widely available -- probably to the point of calling it ubiquitous.

    And therein lies another problem: Paying for it in a form than any idiot can easily use without prior instruction! Yes, the original patent has expired, and injectable naloxone in small, sterile containers is now cheap. But that’s not how we’d need to spread naloxone far and wide. What we’ll need is either a delivery system (injector) that doesn’t cost $100 per injector (yeah, the drug is cheap, but the injector is still under patent protection) or a new way to deliver it -- perhaps a nasal spray? And we need whoever develops it to place it into the public domain otherwise we’ll be faced with an expense for the antidote that will seriously deplete whatever public funding source we decide to use!

  6. says

    cartomancer --“…in the US, since opiate-based medicines are massively over-prescribed…”

    Are you kidding me? As someone who is living with chronic pain, and limited to naproxen, I’d love to know where they’re just handing out opioids like candy, ‘cuz it sure ain’t here!

  7. says

    I can walk into Safeway here in Edmonton and get a naloxone kit for free, but we’re also accustomed to being able to see a doctor with no out of pocket expenses. I don’t know if it’ll be that easy in the US.

  8. jrkrideau says

    @ sjdorst & Tabby Lavalamp
    Not sure if it quite as easy in Ontario as in Alberta but apparently any pharmacy will dispense to someone with need at no cost to the recipient. Province pays $120/injectable and $70/ nasel naxalone kit.

    A friend of mine who needs prescription opiates had his doctor prescribe one just on the off-chance that, after 10 years on the opiate, he might somehow overdose.

  9. kestrel says

    The Partner (who works in the ER at the local hospital) says that Narcan (Naloxone) is already available for real cheap/free in a nasal spray. When someone comes in with an OD, if they survive, they send them home with Narcan. The nasal spray is better because it delivers the drug a little bit slower than if it were injected. The Partner says that people have arrived at the ER with a person overdosed in their car, and they often actually have Narcan in the glove box of the car. Why they did not administer it is not explained of course…

    I agree with cartomancer @#2 that the underlying cause is socio-economics. For one thing, the “war on drugs” in the US has only made things much worse.

  10. agender says

    WMDKitty--Survivor, I must agree with you.
    I looked up the good old opioid tramadol I get regularly (Germany, prescription, for 15 years now, my pharmacy knows to get me the free version, there are some retard formulae which cost 5 Euros per 100 capsules; last week my MD made a liver test, all o.k.), and found out that in the US it is on some “war-against-drugs” list!
    I wish I could help you with something more than best wishes!!!
    Seems that you, cartomancer, believed some piece of sadistic propaganda this time!
    I could not concentrate on computer without my painkiller (in the last years I have not heard anything else than “take your pills according to the clock, so you will not get addicted!”)
    Of course many retard formulae do not work as long as they are advertised to do, and THAT is a little problem, but legal drugs are pure and the dose is what is written on the package -- only illegality creates drug wrecks!!!!

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