By Mark Gold, MD
Synthetic opioids like fentanyl accounted for around 3,000 deaths in 2013—by 2018, they accounted for over 30,000.1 Fentanyl is approximately 100 times more potent than morphine, 50 times more potent than heroin. Breathing can stop after use of just two milligrams of fentanyl. That’s about as much as trace amounts of table salt. “Ten years ago,” write the authors of a recent RAND report on the future of fentanyl, “few would have predicted that illicitly manufactured synthetic opioids from overseas would sweep through parts of Appalachia, New England, and the Midwest.” Drug epidemics and outbreaks can be surprising, taking unexpected forms at unpredictable moments in uncharacteristic patterns. But the fentanyl crisis is different. It isn’t just distressingly surprising or one more deadly drug epidemic in a grueling, tragic history of new contagions. Its magnitude, intensity, and sharp variations dwarf previous epidemics with which experts and officials are familiar, and its challenges for public health are novel and, so far, unmanageable. The recent RAND report is a comprehensive overview of the fentanyl crisis’s origins, present status, and, most disturbingly, future.
What did this report find about the future of the fentanyl crisis?
This report finds that, “however bad the synthetic opioid problem is now, it is likely to get worse before it gets better.” Using a large variety of sources, including data on mortality, drug seizures, expert interviews, and a wide array of research on drug epidemics and markets, this report places the fentanyl crisis in historical context and maps its current trajectory. It finds that the crisis developed from a number of causes. The net result has been a decline in U.S. life expectancy, which had not fallen in the past 100 years. In 2014, U.S. life expectancy was 78.8 years. It fell to 78.7 years in 2015, and in 2016 and 2017, it hit 78.5 years.2
Drug overdoses generally, suicide, and fentanyl have been blamed for this national life expectancy reversal. Fentanyl production has boomed. The ease of manufacture in unregulated sectors of the Chinese and Mexican economies is difficult for U.S. authorities to curb or eliminate. The internet promotes novel strategies for synthesizing the substance, spreading its production across many labs; suppliers use US Mail for distribution; and e-commerce helps to get the drug from manufacturers to US consumers for fentanyl transactions. This report observes that for only $10 through the postal system, suppliers can ship a 1-kg parcel from China to the U.S., and private shipment costs about $100. And with large volumes of legal trade between the two countries making rigorous scrutiny of products difficult, especially given the light weight of fentanyl, suppliers find it relatively easy to hide illicit substances in licit shipments.
Interestingly, this report also finds that while fatal overdoses from synthetic opioids have risen markedly between 2013 and 2017, attendant deaths are confined to certain areas of the country: New England, Appalachia, and the Midatlantic. In some parts of the U.S., fatal overdoses from heroin and seizures of the substance have fallen, suggesting that fentanyl isn’t just complementing heroin, but may be replacing it in certain markets. Elsewhere, fatal overdoses are rising from different kinds of synthetic opioids. This bleak picture points to a crisis that escalated rapidly and is now evolving rapidly—and this report expects it to get worse.
Our possible fentanyl futures
This report presents several possible future courses for the fentanyl crisis. One optimistic scenario is “flash and recede”: use accelerates rapidly and then diminishes, which has occurred in California with fentanyl before, and in some countries in Europe. The authors of this report think this is unlikely. A recent paper on this subject was not very optimistic, either. In a thorough and detailed study in Science, researchers examined drug overdose deaths and unintentional drug poisonings in the U.S.3 They demonstrated that drug overdoses may look like they come and go, but in reality, they grow year after year, and grew exponentially from 1979 through 2016 along a remarkably smooth trajectory for at least 38 years. The trajectories of mortality rates from individual drugs can be deceiving. Cocaine was a lead devastating substance in 2005–2006. The three waves of the current opioid crisis followed: prescription opioids, heroin, and synthetic opioids.
Epidemics that have flashed and receded in the past required intensive labor—growing substances, extracting them, and getting them to market. They did not involve a simple, easily shared recipe leading to an expansive network of global and decentralized production facilities. The DEA found that manufacturers can obtain the precursor norfentanyl, which can be readily transformed into fentanyl, from foreign and domestic sources, making it appealing for illegal production purposes.4 It’s also appealing because of limited regulatory oversight and dispersed supply chains across the United Kingdom, Switzerland, Japan, India, Hong Kong, Germany, China, and Canada. Chemists, in short, can make fentanyl all over the world at a very low cost. Fentanyl can still expand into more markets in the U.S., is very inexpensive, and, in contrast to behavior during the cocaine epidemic, evidence suggests that people won’t quit the substance after finding out how dangerous it is. They already distrust it. Fentanyl could spread to the American west, in this case, if it is mixed with or replaces black tar heroin popular there, or stay in its current markets. In another scenario, it could replace heroin’s market share altogether, given how inexpensive it is for suppliers, and in another, it could remain part of a market with heroin if some consumers prefer to pay more for heroin. Another possibility is that synthetic opioids become a standard part of substance use in the U.S., or even get overtaken by another, faster-growing meth or cocaine epidemic.
Why is this important?
If this report is right, it confirms the one-epidemic-after-another style of thinking, and adds to it the ominous specter of a business model that has room to grow: easy, dispersed global production and low-cost shipping. Fentanyl has come to define substance use in the U.S., eclipsing every other drug in the deadliness of its market share. The prospect of fentanyl displacing heroin in the entire US market is particularly troubling. One of the report’s key findings is that fentanyl’s death toll doesn’t grow because of new consumers, but because it replaces less deadly opioids among individuals with OUD. An arresting statistic from the report is that if, in 2017, other parts of the U.S. had synthetic opioid fatalities at even half the rate of New England’s, we’d have had about 9,000 more drug deaths.
In an LA Times op-ed, three of this report’s co-authors call for curbing the spread of fentanyl from its current locations in the country to limit these thousands of looming potential deaths.5 This may sound like a dispiriting half measure. But it is dispiriting: they frame the fentanyl crisis as a poison control problem because the deadly substance exists and our goal, they argue, should be to limit exposure. This report says that there are some variables influencing the possible futures of fentanyl—the extent to which the crisis is created by a negative heroin supply shock, whether consumers actually prefer heroin, how much less expensive heroin actually is—but these conditions don’t affect the underlying reality much. This also means, these authors say, that the usual suite of policy responses to drug epidemics won’t cut it with fentanyl. Instead, they urge new tactics, like hacking websites that sell fentanyl. This report itself hopes for a host of “innovative” responses, including not-yet-existing technology, and considerably enhanced data collection on substance use and markets. The DEA has proposed a supply chain or precursor control to slow or reduce illicit fentanyl production. In September, it presented plans make the fentanyl analog and chemicals benzylfentanyl and 4-anilinopiperidine controlled chemicals under the Controlled Substances Act, and to make norfentanyl a Schedule II controlled substance.6 DEA has also established new heroin-fentanyl enforcement teams.
According to the CDC, our funding, enforcement efforts, and prevention activities on the opioid epidemic have had some effect, with 25 states reporting opioid death decreases of five percent overall.7 But fentanyl-related deaths are still rising. In a stark reminder that we do not have a mono-drug epidemic, benzodiazepines, cocaine, or methamphetamine were present in 63% of opioid deaths. A recent study observes that young adults are significantly raising their intake of stimulants and opioids, often while binge drinking.8 Polysubstance use is our new normal. This is in part why many experts stress the importance of starting prevention efforts early in life, preferably before the age of 12.9 We have to hope that a trend among the young10 to reject all tobacco, alcohol, and illicit substances grows and that some of our prevention, early intervention, enforcement, and other responses work . The current evidence is a dire warning, a brutal prediction of a drug epidemic building on epidemics of the past, and coming suffering on a massively expanded scale. However you characterize the current fentanyl crisis, as a poison control problem or natural disaster or astoundingly bad drug epidemic, it’s one of the worst the country has ever experienced. And it’s hard to disagree with this report’s conclusion that it’s only getting worse.
Pardo, B., Taylor, J., Caulkins, J.P., Kilmer, B., Reuter, P., Stein, B.D. (2019) The Future of Fentanyl and Other Synthetic Opioids. RAND
DeWeerdt, S. (September 11, 2019) Tracing the US opioid crisis to its roots. Nature
Jalal, H., Buchanich, J.M., Roberts, M.S., Balmert, L.C., Zhang, K., Burke, D.S. (2018) Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science
Drug Enforcement Administration. (September 17, 2019) Control of the Immediate Precursor Norfentanyl Used in the Illicit Manufacture of Fentanyl as a Schedule II Controlled Substance. Federal Register Volume 84, Number 180
Pardo, B., Caulkins, J.P., Kilmer, B. (September 1, 2019) Opinion: Treat the fentanyl crisis like a poisoning outbreak. Los Angeles Times
DEA. (September 17, 2019) DEA proposes to control three precursor chemicals used to illicitly manufacture deadly fentanyl. Retrieved from https://www.dea.gov/press-releases/2019/09/17/dea-proposes-control-three-precursor-chemicals-used-illicitly-manufacture
Gladden, M., O’Donnell, J., Mattson, C.L., Seth, P. (August 30, 2019) Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines, Cocaine, and Methamphetamine - 25 States, July - December 2017 to January - June 2018. Morbidity and Mortality Weekly Report
Philbin, M.M., Mauro, P.M. (October 1, 2019) Measuring polysubstance use over the life course: implications for multilevel interventions. The Lancet
DuPont, R.L. (February 16, 2018) Reducing Future Rates of Adult Addiction Must Begin with Youth Prevention
Levy, S., Campbell, M.C., Shea, C. L., DuPont, R. L. (2018) Trends in abstaining from substance use in adolescents: 1975-2014. Pediatrics
1. Pardo, B., Taylor, J., Caulkins, J.P., Kilmer, B., Reuter, P., Stein, B.D. (2019) The Future of Fentanyl and Other Synthetic Opioids. RAND
Dr. Mark S. Gold is a teacher of the year, translational researcher, author, mentor and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine and food. Read more by Dr. Gold here.