PROVIDENCE – In 2015, nine years ago, the Drug Enforcement Agency and the Centers for Disease Control and Prevention issued alerts about the developing danger of fentanyl.

The alerts specified that there were “a sharp increase in the availability of counterfeit pills containing varying amounts of fentanyl and fentanyl-related compounds; a widening array of toxic fentanyl-related compounds being mixed with heroin or sold as heroin, and continued increases in the supply and distribution of illegally manufactured fentanyl.”

At worst, many national policy makers and public health authorities initially discounted the alerts; at best, they were tragically slow to react.

After a sluggish start, federal and state authorities have reacted with policies, legislation, and funding to try to manage the devastation caused by fentanyl.

And now, in 2024, fentanyl has come full circle, achieving the status of presidential campaign fodder.

Hyperbolic misinformation.  
Consistent with the political campaign tradition of hyperbolic misinformation, the current misleading assertion is that illegal and legal immigrants are the fenatanyl “drug mules.”

In December of 2023, the Department of Homeland Security reported that “more than 90 percent of fentanyl interdicted is stopped at Ports of Entry [(POE] where cartels attempted to smuggle it through, primarily in vehicles driven by U.S. citizens.”

According to the U.S Customs and Border Protection agency, 88 percent of seized fentanyl was at Ports of Entry and 80.2 percent of the “drug mules” were U.S. citizens.

A recent New York Times story, headlined “The American Drug Mules Smuggling Fentanyl into the U.S.,” attempted to explain the rationale – a rationale that seems to escape our politicians, i.e., why would the cartels use stereotypical immigrants when they can use American citizens, who are always less scrutinized at the border.

The cartels recruit at bars, gyms, rehab facilities, high schools, and trailer parks. For example, a mother raising three special-needs children took the job while facing eviction. A homeless man was recruited from an encampment in a Walmart parking lot.

The “mules” are interchangeable and disposable, and the “merchandise” is expendable and can be quickly replaced. 

The deadly equation    
Reportedly, the $800 worth of chemicals that it takes to produce one kilogram of fentanyl can yield a net profit of up to $640,000. The recruiters offer anywhere from $1,000 to $10,000 to couriers desperate for money for what is described as “a few hours of low-risk work.”

The job requirement is an American citizenship and the ability to drive a car across the border. According to Customs and Border Protection, almost all of the fentanyl found at the southern border arrives in cars or tractor-trailers, of which only 8 percent are scanned for drugs.

As a result, the overwhelming amount of fentanyl which makes it into the U.S. continues to drive the high rates of non-fatal and fatal opioid drug overdoses.

Last year, 115,562,603 pills containing fentanyl – and 27,000 pounds of fentanyl – were seized by law enforcement last year, according to federal authorities.

Here in Rhode Island    
We were recently reminded of this [as if we needed a reminder] when the R.I. Department of Health issued a public health advisory because the Woonsocket community had experienced an increase in the number of drug overdoses in late September.

Overall, the Woonsocket community has experienced a significantly higher rate of overdose burden that is more than twice the statewide average. There was a rate of 376 non-fatal opioid overdose reports in Woonsocket per 100,000 residents, compared to the statewide rate of 185 reports per 100,000 residents.

Woonsocket also recorded the highest rates of fatal overdoses in the state last year, with approximately 68 deaths per 100,000 people. The city was followed by Providence [more than 53 overdoses per 100,000 people], Pawtucket [nearly 47 per 100,000 people], and East Providence [nearly 32 per 100,000].

The politics of drug ODs    
The politicization of issues related to drugs continues to be disturbing, but totally predictable.

Historically, the tactic of using some variation of running against “drugs” is always an irresistible, sitting-duck target for candidates who are frightened to be seen as “soft on crime.”

But with fentanyl, the politicians may now be a day late and a dollar short. The recent report by state authorities that there was a decreased opioid overdose death rate of 7.3 percent in Rhode Island in 2023 was so encouraging to all of us.

Also encouraging was the Kaiser Family Foundation report that opioid deaths dropped in about three-quarters of the states during the last half of 2023. And, according to the CDC, fatalities from [all] opioid overdoses nationwide fell an estimated 4 percent in 2023.

Even better, CDC reports that fentanyl overdose deaths dropped by 10 percent from 2022.

Translated, this may mean that we are seeing the beginning of the end of the fentanyl cycle, which would be consistent with the cyclical nature of national illicit drug use.

A story from NPR this month reports that Dan Ciccarone, a physician and street drug researcher at the University of California, said that, over the past six months, he began hearing from drug experts around the U.S. who are seeing significantly less fentanyl and fewer overdoses. Some of the top drug policy experts, as well as experts with close ties to street fentanyl markets, believe the data shows a major disruption in the deadly fentanyl supply chain.

The story cites Vanda Felbab Brown at the Brooking Institution, who said that drug gangs appear to be trafficking less fentanyl and are also adulterating the potency of the fentanyl being sold and that “everyone has been caught by surprise by the extent of the adulteration of fentanyl.”

Researchers generally agree there has been an “unprecedented” drop in fentanyl purity in some parts of the United States. Labs that test street fentanyl are finding it cut or watered down far more aggressively.

A convergence of factors    
It is too soon to determine the reason for these fatality rate decreases, but at this point the consensus is that it is a convergence of multiple factors. 

Those factors include: the shift in the drug supply; increased seizures; stepped-up pressure on the Mexican cartels; the spread of naloxone [including the over-the-counter availability of Narcan (around $45 for a 2-dose, 4 mg nasal spray); the DEA’s One Pill Can Kill national campaign; improved access to treatment that includes lower barrier access to buprenorphine; increased access to Methadone Maintenance Treatment due to the relaxation of regulations and the approval of mobile treatment; low barrier access to harm reduction supplies such as fentanyl test kits; and increased funding from the opioid response grants and opioid settlement funds (last month we learned that the state will receive $11.4 million over the next three years through the State Opioid Response grant).

The big if.  
If fentanyl distribution does in fact taper off, the reality is that our nation’s demand for drugs will remain constant, and we can be sure that the illicit drug developers are already at work to meet that demand.

It is not too early to prepare for the new wave of toxic illicit drugs, whatever deadly form they take.

The challenge for our national and state drug policy going forward is that we must make it easier to get into treatment than it is to obtain fentanyl – or any other illicit drug.

Further,  our policy going forward must reflect the reality that the illicit drug market is rapidly moving from agriculturally-based drugs such as heroin, cocaine and leaf marijuana to new synthetic drugs, such as xylazine, nitazenes, very toxic P2P methamphetamine [as opposed to the old ephedrine-based meth] and synthesized cannabinoids.

And it’s likely that this list will be outdated soon, as the chemists in the transnational criminal organizations are continuously cranking out new psychoactive substances that are continuously tweaked to avoid drug laws.

The perils of prohibition.  
Our policy going forward must reflect a better understanding and acknowledgement of the problems with prohibition, as we re-learned when we decided to drastically cut opioid prescribing.

This action led pain patients to switch to more available and cheaper heroin, and thus set the stage for the introduction of fentanyl as the precursor for the market transition to synthetic drugs.

[What is known as the “iron law of prohibition” states that due to the illegality of drugs, dealers have incentives to produce drugs in more powerful and concentrated forms that are more profitable because they require less storage space, they can be sold for higher prices, and they weigh less in transportation].

Our policy going forward must acknowledge and counter the drug development and marketing skills of the transnational organizations whose simple goal is for illegal drug users to be able to buy more drugs, at higher potency and lower prices, and with more convenient delivery than ever before.

Our policy going forward must acknowledge and account for the 2020 U.S. General Accounting Office statement that: “For 150 years, there hasn’t been a time when massive numbers of Americans haven’t regularly used illegal drugs – today, roughly 1 in 5 use illegal drugs…and that number is on the rise.” 

Collectively, we must keep reminding ourselves that the overdose crisis is not an unsolvable problem, and we can continue to be guided by the words of Carl Erik Fischer, the addiction physician, bioethicist, and person in recovery: “We will not end addiction, but we must find ways of working with it: ways that are sometimes gentle, and sometimes vigorous, but never warlike, because it is futile to wage a war on our own nature.”