According to the Centers for Disease Control and Prevention (CDC), opioids were involved in 47,600 deaths in 2017, almost twenty times than the total number of American casualties in the attacks on Pearl Habor. Overall the number of opioid overdose deaths was six times higher in 2017 than in 1999.
The CDC Injury Center monitors data on four types of opioid: (i) natural opioids, such as morphine, and semi-synthetic opioids, such as oxycodone; (ii) methadone, a synthetic opioid; (iii) other synthetic opioids; and, (iv) heroin.
Their analysis shows three waves of opioid overdose-related deaths hitting the United States: a steady rise in prescription drug overdose deaths starting in 2000; a heroin overdose death spike from 2010 onwards; and, perhaps most troubling of all an explosion in the rate of fentanyl-overdose deaths, which started skyrocketing in 2013.
While drug overdose-related death rates increased across all demographic categories, rates of drug-poisoning mortality were highest among men, among people in the 25-34 age group, and among non-Hispanic whites. Recent spikes in heroin and fentanyl overdose-related deaths speak to a national crisis that the United States is only starting to come to terms with.
Recent Measures
With more people dying from opioid abuse than perennial killers such as influenza or chronic liver disease,12 American lawmakers and law enforcement agencies have had to adopt a multi-faceted approach to the crisis.
Given the sheer lethality of the drug, one of the top priorities for US foreign service officials is eliminating production of and trade in fentanyl globally. To illustrate highlight fentanyl’s potency, United Drug Enforcement Administration (DEA) released a sobering picture of 2 mg of fentanyl, a lethal dose for most adults, next to a penny.
In a tweet on 23 August 2019, President Trump castigated the Chinese Government for its failure to curtail fentanyl production and trafficking. Recent seizures of fentanyl have found quantities of the drug large enough to wipe out the population of entire states, and US authorities frequently identify China as the origin of the drug.
For instance, in a report by AP, China was tagged as the origin of the “vast majority” of the fentanyl seized in the Operation Cookout drugs raids. “The illicit fentanyl that’s coming in, the vast majority is from China and a lot of it is coming in through the mails,” said G. Zachary Terwilliger, the U.S. attorney for the Eastern District of Virginia, during a news conference. In that raid alone, according to the website of the Department of Justice of the Eastern District, the Feds captured “enough fentanyl to kill over 14 million people”.
Needless to say, China has denied that it is the source of fentanyl in the United States, but at the same time also claims that it is making extensive efforts at controlling the synthetic opioid.
There have been some positive steps towards increased cooperation between the United States and China in this area. The White House released a statement describing a meeting with President Trump in December 2018 where “President Xi agreed to designate the entire class of fentanyl-related substances as Controlled Substances, meaning that people manufacturing and trafficking fentanyl into the United States will be subject to maximum penalties under Chinese law.” Just last week, the Chinese Government also announced the prosecution of a number of alleged fentanyl producers and traffickers.
The Legislative Response to the Opioid Crisis
More positively, a statement issued by the White House highlighted reductions in opioid-related deaths since 2017, with the Council for Economic Advisors (CEA) estimating that almost 30,000 lives had been saved over a two-year three-month period.
Compared to the previous trend for monthly opioid-related overdose deaths, CEA estimates that almost 30,000 lives were saved from January 2017 through March 2019 (the latest available provisional data).
Among the legislative measures reported to be impacting opioid deaths is the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT for Patients and Communities Act), which enjoyed bipartisan support and was signed into law on 24 October 2018. The SUPPORT Act is a comprehensive bill that tackles multiple aspects of the epidemic including treatment, prevention, recovery and enforcement, although it should be noted that many of the provisions of the law are yet to take effect. For instance, Section 1003 authorizes CMS to conduct a 54-month demonstration project to increase substance use provider capacity, beginning with this 18-month planning phase. Upon completion of the planning phase, up to 5 states will be selected to carry out a subsequent 36-month demonstration. The closing date for applications was 9 August 2019, so while benefits from the initiative may be felt in the target states before then, the final results from the demonstration project will therefore not be available until 2022.
Section 1004 provides that “State Medicaid programs must establish drug-review and utilization requirements, including safety measures for subsequent prescriptions of opioids.” An example of its implementation can be found from the state of New Mexico, which issued on 2 October 2019 a Supplement to the Medical Assistance Program Manual. The supplement mandates prospective and retrospective safety edits, “identified by duplicate fills, early fills and/or quantity limits”, morphine limits for patients with chronic pain in outpatient settings, and concurrent utilisation alerts. It is unclear whether all states have complied with the requirements of this law.
Title II of the Act introduces a number of measures to address the opioid crisis, including a liberalisation of geographic restrictions on substance-use disorder telehealth services; substance-use disorder screenings; digitisation of prescriptions for controlled substances; drug-management programs for at-risk beneficiaries; expansion of Medicare to cover certified opioid-treatment programs; improved communication on those at risk of overdosing; and, penalties for non-compliant pharmacies.
Title III mandates increased control of controlled substances. For example, under Section 3022, the US Food and Drag Administration “may prohibit a person from importing drugs or controlled substances under specified circumstances, including if the person has shown a pattern of importing adulterated or misbranded drugs that pose a serious health threat”.
Analysis
Success for US lawmakers will clearly come in the stages, starting with arresting the alarming upwards trend in opioid overdose deaths. While it is surely not possible to reduce opioid overdose rates to near-zero, reducing the rate to 2000-levels, in the present context, would represent a significant success, not just for the White House or Congress, but for all US agencies working on this issue, and ultimately for the American people.
Diplomatic niceties should never stand in the way of calling out countries that fail to prevent the production of narcotics on their territory. President Trump’s willingness to call out the Chinese Government has clearly rattled Beijing as can be seen from their contradictory response both denying there is a problem and promising to address it.
Given the lethality of fentanyl, participation in its production or trade should be viewed as equivalent to an act of war. Fentanyl is a chemical weapon that has the potential to be used against civilian populations, and must be responded to with the utmost ruthlessness. For all countries affected, fentanyl-trafficking must be treated as a national security issue, and the fullest efforts of lawmakers, diplomatic corps, border control agencies, and law enforcement agencies should be directed to the elimination of its production and trade.
At the same time, substance abuse more generally is indicative of a hopelessness and malaise affecting modern Western societies surely have their root in a broader spiritual crisis. In the absence of public Christianity and organic communities comprised of healthy social institutions, the temptation to seek relief in narcotics, from the purposelessness of an abusive, exploitative and atomising culture, will only be too great.
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