Highly potent fentanyl analogs are playing an increasingly prominent role in opioid-related deaths, accounting for one in five such fatalities during the year ending in June 2017, according to a new CDC analysis of data from 10 states. During that period, the CDC counted 11,045 "opioid overdose deaths" in those states, including 2,275 cases where fentanyl analogs were detected. The number and proportion of deaths involving fentanyl analogs "nearly doubled" between the second half of 2016 and the first half of 2017. This trend is yet another illustration of prohibition's effectiveness, assuming the goal is to make drugs as deadly as possible.
Most opioid-related deaths now involve illicitly produced fentanyl. In the 10 states tracked by the CDC (Kentucky, Maine, Massachusetts, New Hampshire, New Mexico, Oklahoma, Rhode Island, West Virginia, and Wisconsin), fentanyl was detected in 57 percent of opioid-related fatalities from July 2016 through June 2017. Fentanyl analogs showed up 21 percent of the time. The most commonly detected analog was carfentanil, followed by furanylfentanyl. Ohio alone accounted for 90 percent of the 1,236 carfentanil deaths in the 10 states during this period. The other analogs detected were 3-methylfentanyl, 4-fluorobutyrfentanyl, 4-fluorofentanyl, 4-fluoroisobutyrfentanyl, acetylfentanyl, acrylfentanyl, butyrylfentanyl, cyclopropylfentanyl, cyclopentylfentanyl, furanylethylfentanyl, isobutyrylfentanyl, and tetrahydrofuranylfentanyl.
The CDC notes that "carfentanil, the most potent fentanyl analog detected in the United States, is intended for sedation of large animals and is estimated to have 10,000 times the potency of morphine." By comparison, the National Institute on Drug Abuse says fentanyl is 50 to 100 times as potent as morphine, while heroin is said to be about twice as potent as morphine. Prescription conversion tables indicate that hydrocodone (the opioid in Vicodin) is about as strong as morphine, while oxycodone (Percocet) is a bit stronger.
In other words, the crackdown on prescription analgesics is pushing opioid users toward increasingly potent substitutes: heroin (roughly twice as potent as morphine), which is often mixed with or replaced by fentanyl (50 to 100 times as potent) and fentanyl analogs (as much as 10,000 times as potent). Worse, the purity and potency of black-market drugs are highly variable and unpredictable, making consumers vulnerable to lethal dose miscalculation, especially when they are taking more than one substance at a time (as is typically the case in drug-related deaths). The wider the range of purity and potency, the greater the potential for fatal mistakes.
Prohibition contributes to this problem in several ways. It creates a black market where consumers don't know what they're getting, encourages dilution along the supply chain that dealers may try to counteract by adding fentanyl or fentanyl analogs to heroin, and pushes traffickers toward more potent drugs, which reduce the volume that must be smuggled for any given number of doses. Increased enforcement of prohibition magnifies these tendencies, exposing users to greater risks and feeding the upward trend in opioid-related deaths.
So how is Attorney General Jeff Sessions responding to the proliferation of fentanyl and fentanyl analogs? With increased enforcement, of course.
Last week Sessions announced Operation Synthetic Opioid Surge, which aims to "reduce the supply of deadly synthetic opioids in high impact areas" by federally prosecuting "every readily provable case involving the distribution of fentanyl, fentanyl analogues, and other synthetic opioids" in 10 U.S. attorney districts. This strategy may send more people to prison for longer periods of time and temporarily disrupt retail markets. But judging from a century of drug prohibition in America, Sessions' innovative plan to arrest and imprison readily replaced drug dealers will not have a substantial and lasting impact on the availability of opioids or reduce the death toll associated with them. To the contrary, the enforcement pressure is apt to make drug use even more dangerous.
"When it comes to synthetic opioids, there is no such thing as a small case," Sessions said in his press release. "Three milligrams of fentanyl can be fatal—that's not even enough to cover up Lincoln's face on a penny." Based on the CDC's estimate, the equivalent amount of carfentanil would be 0.03 milligram, or 30 micrograms, which is not even enough to cover Lincoln's right nostril. Perhaps that is where the market is headed, with a little encouragement from drug warriors like Sessions.