Today’s fentanyl crisis: Prohibition’s Iron Law, revisited

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Abstract

More than a decade in the making, America’s opioid crisis has morphed from being driven by prescription drugs to one fuelled by heroin and, increasingly, fentanyl. Drawing on historical lessons of the era of National Alcohol Prohibition highlights the unintended, but predictable impact of supply-side interventions on the dynamics of illicit drug markets. Under the Iron Law of Prohibition, efforts to interrupt and suppress the illicit drug supply produce economic and logistical pressures favouring ever-more compact substitutes. This iatrogenic progression towards increasingly potent illicit drugs can be curtailed only through evidence-based harm reduction and demand reduction policies that acknowledge the structural determinants of health.

Introduction

The United States is in the midst of the worst drug-related crisis in its history. Over 52,000 Americans were killed by drug overdose in 2015, an increase of more than 300% since the turn of the century. Driven primarily by opioids that kill an average of nearly 100 Americans every day (Rudd, Puja, Felicita, & Scholl, 2016), the grim toll of overdose-related death and disability has reached levels of devastation unseen since the height of the AIDS epidemic.

Like that terrible pandemic and many other public health emergencies, the opioid overdose crisis has multiple, overlapping causes (Park & Bloch, 2016). Initially, one primary cause of the crisis was the over-prescription of opioid analgesics (OA). Most of these prescriptions were issued in good faith, but some providers prescribed (and sometimes dispensed) large amounts of opioids without regard for the patients’ medical need.

In an effort to address opioid overprescribing, policymakers have mounted a series of supply-side interventions. These have included crackdowns on unscrupulous providers and facilities, prescription limits and guidelines, bolstering prescription monitoring systems, reformulation of some OAs to make them more difficult to misuse, and nudging (or threatening) prescribers to curtail the quantity and dosage of opioid prescriptions (Alpert, Powell, & Pacula, 2017). These efforts have seen some effectiveness in reducing the volume of opioids prescribed, and some have been associated with reductions in prescription opioid overdose mortality (Patrick, Fry, Jones, & Buntin, 2016; Rutkow et al., 2015).

These supply-side strategies have seldom been balanced with concerted efforts to engage and retain people with opioid use disorder (OUD) or poorly-managed pain in a comprehensive spectrum of care (Kertesz, 2017; Gellad, Good & Shulkin, 2017). Unfortunately, opioid dependence and addiction do not simply dissipate with the contraction in the availability of OA pills or the introduction of “abuse deterrent” formulations. Instead, individuals who lost access have turned to cheaper, more accessible, and more potent black market opioid alternatives—including heroin—in unprecedented numbers (Cicero, Ellis, Surratt, & Kurtz, 2014; Alpert, Powell, 30 & Pacula, 2017; Park & Bloch, 2016). In concert, prevalence of injection drug use, and its infectious disease sequelae also saw substantial increases (Jones, Christensen, & Gladden, 2017).

Unintended but foreseeable, this transition exposed users to drastically higher risk of overdose because of the lack of regulation over the contents, quality, and dosage in black market opioid products (Alpert et al., 2017, Cicero et al., 2014). Many people with untreated pain and addiction also became shut out from the health care system and the risk-reduction interventions that it potentiated. As a result, after remaining largely stable for years, overdose deaths involving heroin spiked rapidly, tripling between 2010 and 2015 (Cicero & Ellis, 2015; Cicero et al., 2014, Rudd et al., 2016).

As heroin began to devastate suburban and rural communities, renewed emphasis was placed on interdiction and enforcement efforts. This included major scale-up in the staffing and funding of federal agents along the US-Mexico Border, where the amount of heroin seized quintupled between 2008 and 2015 (Drug Enforcement Administration, 2016, Pew Charitable Trusts, 2016). On the domestic front, prosecutors and police reached for their toolkit of harsh criminal penalties, including high-profile prosecutions of overdose victims’ dealers and fellow users. These efforts are increasingly drawing on hitherto seldom-used drug-induced homicide provisions that carry harsh mandatory minimum sentences—an intervention modality that had fuelled mass incarceration, but failed to prevent the worst drug-related crisis in US history (Davis, Green, & Beletsky, 2017; Polcyn & Davis, 2017).

Starting in 2014, the crisis began another transformation. Black market drug products – both heroin and counterfeit pills – became increasingly adulterated with illicitly-manufactured synthetic opioids, mainly fentanyl analogues (Green & Gilbert, 2016). Fentanyl can be synthesised cheaply and with relative ease, and synthesised it has been: In the US, its availability has rapidly grown sourced primarily from China and distributed by Internet cryptomarkets and Mexican drug trafficking organizations (Drug Enforcement Administration, 2016). In the span of a single year, from 2014 to 2015, deaths attributed to fentanyl analogues in America spiked by over 72% to almost 10,000 (Rudd et al., 2016). In an increasing number of locales, these clandestinely-manufactured synthetics now constitute the primary drivers of fatal opioid poisoning (Massachusetts Department of Public Health, 2017, Katz, 2017, Marshall et al., 2017). Emerging year-over-year figures and episodic outbreaks of fentanyl-related deaths paint a grim picture of an uncontained, plague-like contagion.

Section snippets

The Iron Law of Prohibition

These increases in harm were as predictable as they are disastrous. Opioids can be effective in treating acute pain, but they produce dependence when used beyond a limited time period, and can cause addiction in some patients (Dowell, Haegerich, & Chou, 2016). Simply removing access to OAs without replacing this therapy with other pain management modalities and delivering evidence-based opiate substitution treatment could lead only to only two outcomes: increases in untreated pain, unmanaged

The Iron Law of Prohibition revisited: the fentanyl crisis

History repeats itself, Marx wrote, “first as tragedy and then as farce.” The continued emphasis on supply-side interventions to supress non-medical opioid use is both. As this crisis has evolved, the iatrogenic risk to the health of people who use drugs was not just foreseeable, but in some cases directly foreseen by policy-makers (Vaughn, 2016). One of the most shocking articulations of this came from Pennsylvania’s former Physician General, who recently remarked, “We knew that [drug user

Conclusion

Alcohol prohibition, while well-intentioned, was undertaken without sufficient consideration of potential unintended consequences, with disastrous results. Under the Iron Law of Prohibition, the current approach to illicit opioids is likewise doomed to failure. Without serious, sustained efforts to address the direct and root causes non-medical opioid use, intensive supply suppression efforts that brought us fentanyl will continue to push the market towards deadlier alternatives. We must shift

Conflict of interest

Nothing to declare.

Acknowledgements

The authors wish to thank Daniel Ciccarone for invaluable guidance. Leo Beletsky is supported by National Institute on Drug Abuse grants R01DA039073 (MPIs: Beletsky & Strathdee) and R37DA019829 (PI: Strathdee).

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