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Fentanyl (Rauhe/ullstein bild via Getty Images)

Fentanyl, the New Drug Epidemic

David W. Murray

The June 28 release of the 2016 Drug Enforcement Administration (DEA) National Heroin Threat Assessment addresses the emerging scope of the synthetic opioid threat, particularly from fentanyl, a drug which significantly escalates the current devastating heroin and prescription opioid outbreak.

DEA notes that overdose deaths from these synthetics increased 79 percent between 2013 and 2014 alone. These enormously profitable drugs, produced in clandestine labs, are used to spike heroin potency, and are increasingly found in the form of counterfeit prescription pills.

Fentanyl and its analogues, lethal synthetics that are variously reported as 40 to as much as 80 times more potent than heroin, are killing people at an alarming rate.

A potential reason as to why DEA is expressing such alarm now was revealed in April before the Senate Committee on Homeland Security and Governmental Affairs. Testifying before the committee, Commissioner of Customs and Border Protection (CBP) Gil Kerlikowske dropped a bombshell, only now being recognized for its threat impact.

In his testimony, Kerlikowske noted the sharply rising trend of synthetic opioids that CBP is now seizing on the southwest border (the majority of heroin entering the country is trafficked from Mexico). He reported that from only 2.4 pounds of fentanyl seized in 2013, the amount rose to 8.2 pounds in 2014, and to an astonishing 197.8 pounds in 2015.

Fentanyl that is seized at the border, which is likely only a portion of total illicit drug flow, is commonly little more than 10 percent pure. As such, the amount of pure fentanyl circulating in the American illicit opioid market is unknown. But the CBP testimony shows that in three years the amount seized has increased some eighty-three times over, and is likely rising still. This represents a major escalation of the threat.

It is important to stress that this is illicit fentanyl, produced in clandestine labs, in contrast to fentanyl diverted from medical practice (albeit less commonly than opioid drugs such as Oxycodone), where it is used legitimately in anesthesia and pain management.

Fentanyl can be smuggled free-standing or already mixed into a load of heroin, to which it adds intoxicating impact. Fentanyl is so potent that it is extremely difficult to cut or mix uniformly, producing great risk for users. Moreover, new types of synthetics, beyond fentanyl, are now being cooked up in rogue labs—emerging “designer drugs” with analgesic properties orders of magnitude more potent than heroin.

This rapidly evolving threat that takes us beyond the current heroin epidemic, which has already revealed the inadequacies of Obama Administration policy responses. DEA alerts have warned of the dangers of fentanyl to authorities who encounter it, taking us into a realm unlike any previous epidemic.

Beyond just threatening the user, fentanyl’s potency threatens first responders and other officials in the seizure chain of custody with the risk of death from mere incidental contact. So powerful is the drug that doses are measured in micrograms (a millionth of a gram), with 100 micrograms considered a recreational dose, ranging up to 2 milligrams, which is considered to be a lethal dose for users without opioid tolerance. It is so lethal and acts so rapidly that the bodies of victims are found with needles still in their arms.

Even if the total seizures represent a mix with heroin, the potential fentanyl overdose threat is staggering. As the DEA alert notes, the spike in forensic “exhibits” that feature in prosecutions involving fentanyl have shot up from only sporadic in 2013 to an increase of 65 percent between 2014 and 2015, standing now at 13,000 exhibits. The alert concludes: “This is an unprecedented threat.”

For the year 2014, Centers for Disease Control (CDC) data show that fentanyl/synthetics were the primary drugs cited in 5,544 overdose deaths attributed to opioids. That is, of 47,055 American drug-induced overdose deaths in 2014, 18,893 of those deaths have been attributed to prescription opioid diversion, of which fentanyl/synthetics contributed 5,544 (to which toll must be added the 10,574 deaths due to illicit heroin).

For reasons unknown, the Administration continues to direct opioid epidemic policy towards the role of pharmaceuticals, while steadfastly ignoring the rising threat of illicit opioid production and trafficking crossing the border.

Had Health and Human Services not, as some believe, misclassified fentanyl/synthetic deaths in the 2014 mortality report by assigning them (the 5,544) to “pharmaceutical opioids” rather than to heroin-type illicit trafficking, the attributed 18,893 overdose deaths on the “medical” side of the ledger would have dropped to 13,349; that is, the toll would have reflected the steady decline in use and consequences from prescription misuse that began in 2006.

Conversely, an accurate apprehension of the role of illicit labs would have increased the current heroin-classified overdose deaths from 10,574 to 16,118 in 2014. That is, for the first time illicit opioids would have eclipsed the declining pharmaceutical contribution, and would have clearly indicated where the opioid epidemic, still rising steeply since 2010, is now headed.

Because of the inadequacies of nationwide toxicology screens, the apparent precision of a breakdown-by-drug may represent an undercount. As the supply has risen since these deaths occurred, the coming death toll will likely rise even further, at such time when the data disclose the contemporary reality.

Next, the episode reveals the woeful state of the surveillance capacity and Administration neglect of databases and reporting mechanisms. In 2006/2007, a fentanyl outbreak killed scores in Chicago and neighboring cities, generating a crisis. Ultimately, the source was traced to a single clandestine lab in Toluca, Mexico, that the DEA was able to negate. There are eight times as many forensic exhibits since then, but the surveillance mechanisms have not been fortified.

How is it possible that the surveillance and monitoring systems, now years after the first warning, are still not functioning with real-time information? In July of 2016, we still don’t have real-time data to know how many opioid deaths are occurring, or where, nor are we mounting an adequate mobilization domestically or internationally in response.

Our government should be having urgent drug policy engagements with both Mexico and China, the two primary sources of the chemicals, over the deadly flow. Instead, the President’s budget, according to recent testimony of Obama Drug Czar Michael Botticelli, shows a retreat from international engagement, with $952 million in cuts to international drug control programs since 2009.

And finally, the Administration is relying on the same misdirected playbook of the last seven years; criticizing doctors prescribing practices; handing out ever more naloxone — the opioid overdose antidote — no matter the insufficiency in the face of these new potencies; enabling legal drug use in the states; and acquiescing in so-called “harm reduction” drug policy, such as the wrong-headed proposals seeking to provide syringes and heroin to heroin users in government-sponsored “injection facilities.”

Evidence shows that such facilities, where established in other countries, attract only a small proportion of intravenous drug users, who further use them inconsistently, at best. This means that even were such programs established here, overdose deaths will likely still increase sharply.

These responses, which further risk eroding prevention measures and incentives to achieve treatment and recovery, also perpetuate a fundamental flaw—they do not address the causes of the epidemic, which are found in the increasing supply, availability, and acceptability of these poisons in our communities, where quantities the size of a salt grain can take a life.

Fentanyl represents a serious escalation of the epidemic, and worse is on the horizon. How long before someone in the Administration confronts what T.S. Eliot termed “fear in a handful of dust”? Until they do, Americans will continue to pay a deadly price.

This article has been modified from the original version posted on The Weekly Standard. That version can be viewed here.

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