Opium, Prescription Opioids, Heroin, Fentanyl, Fentanyl Analogs
Gresham's Law and the illicit drugs market
Obviously, the illicit fentanyl street market is the biggest drug problem in America. If anyone had any doubts that opioid addiction is in an entirely different league than “addictions” to substances like coffee and cannabis, the inelasticity of the market in illicit opioids should make the differences clear. Anyone who harbors any doubts about how much human suffering opioid addicts endure in their quest to nullify their suffering has only to read a random sample of the personal stories of the addicts on the street.
There are hopeful signs on the horizon, as is indicated by this chart of users of prescription opioids, especially by teenagers:
SAMHSA NSDUH 2020 Report, Figure 16
That’s a welcome decline, because it indicates both a drop in supply and a drop in demand. The numbers are particularly important for the 12-17 cohort, because those are the formative years for developing attitudes toward drugs- especially in terms of which ones to avoid. Teenagers are reckless, naive, and drawn to experiment. But they aren’t entirely stupid. Most of them are capable of absorbing in the information that some drugs can kill, or derail ones life. As of 2020, first time “prescription pain reliever” (i.e., opioid pill) use by 12-17 year olds dropped to 37% of what it was only four years previously:
SAMHSA NSDUH 2020 Report, Figure 24
That’s a particularly important data set, because notwithstanding the fact that most of today’s opioid addict population is now using a street supply- “heroin” or counterfeited pills whose actual main ingredient is fentanyl- most of them got their initial acquaintance with the effects of opioids in an earlier era, when the market was saturated with opioid prescription pain pills. Now that market is recruiting many fewer initiates.
Not to clutter up this post with too many charts, but Table A.19.A of the 2020 NSDUH Report indicates that the age 12-17 consumer market for street heroin- which has never been more than a fraction of the opioid pill demand- has seen an even more dramatic decline between the years 2011-2017, from 38,000 first-time users down to 7,000 first-time users; judging from the entries for 2018-2020, the number is apparently too low for the surveys to provide a close estimate. Furthermore, while the most recent NSDUH charts incorporate a different methodology- evidently providing for a wider number of opioid substances and a breakdown of use patterns related to each specific drug- the relevant numbers from the 2021 report show a continued drop for both the age 12-17 cohort- from 158,000 in 2020, to 130,000 in 2021; and the age 18-25 cohort- from 290,000 in 2020, to 269,000 in 2021. (The total number for “initiation of first misuse of prescription pain relievers” shows a rise in 2021, however, attributed entirely to an increase shown for the “age 26 and over” cohort. In my reading, this is likely due to the incorporation of more substances in the NSDUH survey for 2021, including the more powerful opioids that are most often made available only for the most serious pain conditions, and hence not as easily accessed by younger people.)
The recent restrictive policies imposed on prescribing physicians, pharmacies, and manufacturers have to be credited with much of the drop in availability of prescription opioids. I’m of the mind that the new regime of regulation, restrictions, and quotas has erred too far in the direction of stringency, as if it were possible to undo the adverse consequences of neglect by overcompensating. That doesn’t work, but it’s also to be expected; that’s how humans think, and as a human, I get that. I continue to hope that a useful balance will eventually be struck, based on improved knowledge and better judgement. But even if the current regulatory regime is currently erring in the direction of too much stringency, it does appear to have effectively shut off the mass diversion of prescription opioids. (Shutting down small-time informal diversion is an exercise in futility; opioids remain as one of the most commonly prescribed classes of drugs because pain is such a common complaint- it’s a real thing, hmm?- and opioids are the most effective painkilling medicines for most pain conditions. Some people share their supplies. Even a totalitarian regime would have enormous difficulty in stopping that practice.)
That said, the success in shutting down the clandestine diversion market in opioids has come with a serious side effect: the physical dependence and psychological addiction to this class of drugs is so serious that users already addicted were left in a state of terrible desperation- a desperation that, for a great many of them, could only be alleviated by turning to the illicitly manufactured street supplies. (Compare that with the 1980s cutoff of the market in diverted Quaaludes; the user population responded with a shrug, because while methaqualone isn’t free of addiction liability, its real-world addiction potential isn’t remotely close to that of opioids. I’m not terribly impressed with the redefining of the term “addiction” that I’ve observed over the course of the past 40 or so years; I remember when “addiction” used to mean something. According to the most recent definition, all sorts of things are “addicting”, and almost everyone has an “addiction” of some sort. I don’t think the redefinition has led to an improvement in therapeutic outcomes for people with serious drug problems. Or for anyone else, other than the burgeoning industry of Recovery and Rehabilitation.)
Faced with a shutdown of the pipeline of prescription supplies, the by-then massively expanded U.S. opioid addict population chose the next logical resort: street heroin. The suppliers and their channels had morphed several times over the decades (it’s a long story, a tale for a different post); by the early 2000s, the control over the supply, the smuggling networks, the wholesale outlets, and an increasingly large share of the street retail outlets were controlled by rival Mexican organized crime syndicates (misnamed “cartels”, in the popular parlance) in conjunction with subsidiary franchise networks of Mexicans or Central Americans linked by family, clan, or local origin back in the home country. Business had been booming for Mexican suppliers for years; the largest of the syndicates had annual revenues in the billions. It was a mature business, and increasingly vertically integrated, with a transnational reach. Mexican organized crime networks had grown enormously in wealth and power since 1970s, when their pivotal role in the trans-shipment of cocaine for the Medellin and Cali export enterprises allowed Mexican smugglers a lucrative profit source unmatched by their participation in marijuana smuggling and their relatively minor participation in the heroin trade in those years. Cocaine profits enabled much more bribery, intimidation, and state corruption; the increased political power achieved in the 1980s allowed the syndicates to transform the marijuana cultivation industry from small independent producers to plantation employees (and sometimes enslaved labor) along with continuing to increase market share in the U.S. heroin trade with crudely refined “black tar” processed from locally grown opium supplies. But the mainstay remained their large share of control over cocaine smuggling and distribution- until the next bonanza presented itself: methamphetamine- courtesy of the massive increase in global trade and container shipping, and prompted by U.S. efforts to shut down the domestic illicit manufacture of meth by cracking down on the principal precursor chemical, ephedrine. The Mexican syndicates smelled money- high-purity meth is very uncomplicated to manufacture through the hydrogen reduction method, and hugely profitable- and by the late 1990s, Mexican “superlabs” had begun to swamp out the remaining U.S. competition with massive amounts of methamphetamine selling for silly cheap- but still hugely profitable- wholesale prices. Those profits brought even more opportunities to diversify their product lines and vertically integrate their supply chains all the way to the retail level. By the early 2000s, the Mexican syndicates even began to bid for control over the lucrative market for homegrown sinsemilla marijuana in California and Oregon, intimidating American growers with superior firepower and ruthlessness and importing their own labor force to work growing operations in the countryside, while draining watercourses with pump irrigation for pot grows that were more like plantations than patches of plants grown at the fringes of fir trees on the hillside.
Given their track record of success in meth manufacture using precursors sourced from overseas, it was only a matter of time before the executive leadership of Mexican organized crime got acquainted with the other product lines available in the new frontier of global illicit markets at the advent of the Dark Net/Silk Road/Alphabay era. And when they found out about fentanyl, the cartel kingpins knew they had a winning product on their hands.
Consider the advantages of fentanyl over the product line that it would replace- opium and heroin- given the requirements of an illicit market and the attendant complications for import and export: 1) no need to rely on poppy cultivation, thereby eliminating the expense of paying (or enslaving) thousands of peasants- mostly indios in the Mexican outback- to cultivate the poppies and gather the opium sap from the pods- along with eliminating reliance on an agricultural crop, with its cultivation requirements, sensitivity to floods, droughts, and insect pests, and occasional raids from police paramilitary eradication teams funded by the taxpayers of E.E. U.U., Los Estados Unidos (ironically, some of those taxpayers also comprise part of the consumer market for the export product…); 2) less of a requirement to play elaborate games in order to effectively smuggle the export product across international borders, due to switching from heroin to fentanyl. For comparison:
Heroin- diamorphine, diacetylmorphine- requires refining and chemical modification of its precursor chemical, morphine. Morphine is a chemical compound naturally sourced as part of the chemical profile of the sap of the opium poppy, where morphine is the chief actively present ingredient: opium is about 10% morphine. Heroin is about 2.5 times as powerful as morphine by weight in pure form (see chart at the bottom of the page), although the crude refining process most commonly used in Mexico only manages to yield an end product more in the range of 10% heroin than 70%. (I gather that the syndicates have done much, much better with their meth yields.) Black tar heroin is also stinky as all get-out, smells like vinegar. (The smell is due to the unreacted reagents used to turn the morphine into black tar heroin, which I gather is one of those simple, quick and dirty processes, compared to methods that turn out a more pure product. And no, I’ve never used any. A friend showed me some once. A hefty thumb-sized chunk, cost him $25. I mean, good Lord. It was cheap as a gram of BC bud.) Black tar heroin is easy for a dope dog to detect.
Fentanyl is a synthetic product produced in a laboratory. It bears no more relationship to morphine or heroin than synthetic THC analogs bear to natural cannabinoids refined from cannabis plants. It’s around 40 times as powerful as heroin, by weight: using 10mg heroin as a dose, an equivalent dose of fentanyl is 250mcg- 1/4 of a milligram. Considered in terms of volume, it’s the difference between smuggling a pack of cigarettes and smuggling a packet of artificial sweetener. Theoretically, thousands of doses of fentanyl can fit into a US postal service first class envelope without even the requirement for a stamp. Although I guarantee the fentanyl isn’t as easily sniffed out as black tar heroin, I suppose that fentanyl might conceivably have a signature odor, as with many other refined chemicals. But when there isn’t very much of it to sniff, it draws a lot less attention from dope dogs. Especially when it isn’t even being smuggled through the parcel section of the mailroom.
Okay. Moral externalities aside, all business- it makes sense to switch products, right? Especially when you learn that fentanyl is so easily shipped in pure form from chemical laboratories overseas that it’s as if it’s quasi-legal. At minimum, that means a couple of years of flying under the radar making bank before it starts becoming necessary to get your own labs.
That’s what happened with the Mexican syndicates. And then they got a market gift, of all the opioid-dependent street addicts who had just been deprived of their big rock candy mountain of diverted pharmaceuticals.
Fentanyl is near the bottom of preferences for opioid addicts. Given their choice, a lot of opioid addicts would even prefer codeine (which used to be legal, before it was ordained a “gateway drug”…???) The addicts aren’t looking for maximum potency to the point where Russian roulette is the objective. But if it’s the only game in town, they’ll use it. I mean, consider the desperation of people forced into a corner to stretch out their opioid supply with xylazine. Or bathtub “Krokodil”, in similarly prohibitionist Russia. (Incidentally, the currently ongoing Ukro-Russian War is liable to substantially increase the number of opioid addicts in both of those countries for many years to come.)
Fentanyl has to have made the Mexican syndicates a fortune, what with cutting so many production costs- and, at the outset, silly cheap prices for a substance that could be supplied in the millions of dosage units, pure and refined from high quality labs. Another interesting feature of the Mexican fentanyl trade is that some of the smuggling networks appear to be so secure that they feel no requirement to take advantage of the weight and volume strength of pure uncut fentanyl for cross-border smuggling: they’re tabbing it up as “M30” pill tablets, big bales of them. Not the move I expected, but it probably makes sense- because the single most pronounced drawback of fentanyl is the difficulty of establishing a uniform level of purity for the retail market, given that it produces threshold effects at the weight of 1/10 of a milligram. So it appears that the wholesalers are mostly tabbing the pills up south of the border, in big pill mills. More for convenience than safety, as should be needless to say.
The first time I ever heard of fentanyl was as an drug profile entry in the pages of High Times magazine, in the late 1980s iirc- pretty much like the sort of snyopsis one might read from Drugs.com or some similar site. I read that and thought, that’ll never catch on: too hard to tab up safely, and any illict chemist without a first-rate well-equipped lab, a hazmat suit, and a rubber glove box would probably not survive the end stage of their first attempt at synthesis.
But maybe I’m wrong. Although I’m still puzzled over the PBS “on-site report” by a pretty young female reporter of her on-site visit to a Mexican cartel fentanyl factory'“ that featured a couple of guys dumping some white powder into some sort of dark, oily liquid. It just didn’t fit the picture that I had in my mind, about how to refine fentanyl. The fixings didn’t even look like they were especially professionally mixed. It looked like something you’d mix with a butten churn, or a paddle.
(But maybe it is that easy- I really don’t know. At one point I did track down how fentanyl was invented and by who, and learned that the formula is public, requiring six basic ingredients that are nowhere near as easily controlled as, say, P-2-P, or ephedrine and pseudophrine. But it still at least sounded as if it were a more complicated process than what I saw on that broadcast.)
If the history of smuggling is considered over the course of human history, fentanyl must represent some sort of endgame. The corollary of Gresham’s Law applied to forbidden drugs indicates that more compact and powerful commodities that retail for higher prices drive out the products with fewer of those market advantages. The market for cocaine increased in the 1970s because smugglers who had already found secure routes for smuggled marijuana found it much more lucrative to ship the same quantity of a refined powder that sold for 10-30 times the price per kilo (or more.)
The paradigm also helps to explain why no one bothered to bootleg methaqualone after it was banned in the US: the smallest effective dose of Quaalude is 150mg, and the most popular tablets were 300mg. Not worth the hassle to manufacture and smuggle. (There was a brief run of counterfeit Quaaludes right after they were banned- but the tablets actually substituted a large quantity of Valium. An unpopular alternative, and a market failure. The recently popular prescription tranquilizer Xanax- active in the 0.5mg range- has proved to be more popular as a bootlegged drug. One of the most powerful benzos by weight, and coincidentally rarely prescribed until after Quaaludes had disappeared from the pharmacy shelves.)
As for marijuana itself, the conditions of the clandestine market made it virtually inevitable that 2% THC marijuana would be followed by 5%, 10%, 20%, 25% THC marijuana- not so much due to the clamor for an ever-more potent product (although there was some of that, particularly at the outset), but simply due to the inherent pressure of a smuggling market, which at the mass-market level practically always favors the higher profit margin from a more concentrated product that’s more compact and easier to store and smuggle. The same situation applies to all of the most powerful illicit powder drugs; because they’re so easily smuggled and transported, they eventually make an appearance in underground retail markets whether anyone has been requesting their presence or not. In a market controlled by criminals, ethical reservations about selling more hazardous products have a way of corroding. It certainly isn’t as if there’s any effective regime of uniform regulatory control. And once the substances advertise their availability, some percentage of a customer base for mind-altering substances is curious enough to try them.
Up to a point.
That’s one of the most interesting facets of the current fentanyl crisis. It’s noteworthy that the recruitment of new users to the product has been remarkably low. The cartels are even experimenting with putting little tastes of it into their other product lines, but it doesn’t seem to have paid off for them. Most humans have a setting that finds opioids to some extent pleasurable, and some even have a particular vulnerability to them. But not when their presence shows up as a nasty and potentially lethal surprise. Even that self-selecting fringe group that we have with us always- the one that embraces the dubious charms of playing in the illicit street life and the decadent demimonde scene- tend to be turned off by the prospect of playing Russian roulette with street fentanyl. Most of them have to be already entrapped.
Fentanyl is currently the staple of the illicit opioid market because it has a captive population of customers: the consumer base built up between the early 1990s and the early 2010s. I know from my reading that there are some individual variations of taste in particular opiates or opioids in the opioid user population. I also know from my reading that few opioid fanciers really like fentanyl all that much, much less preferring it to other opioids. But the finer points of personal preference assume much less importance for addicts forced to rely on the street market. Addicts dependent on street supplies will take anything that they can get. And that’s what they’re doing, with fentanyl. Despite the fact that fentanyl is so scarily strong that as little as half a milligram can kill a user who hasn’t developed opioid tolerance, the confirmed street addicts still buy it and use it, day in and day out. And the results can be read in the headlines: they’re dying in droves.
The chances of interdicting the fentanyl supply before that situation runs its course are nil. Zero. Impossible. There hasn’t been a heroin shortage impactful enough to depress user demand in the United States since the 1930s, if ever. So how can anyone expect to stop the supply of fentanyl? Anyone who implies that fentanyl has to be made in Foreign Lands doesn’t know the deal. Nothing rules out fentanyl being made in Idaho.
Fentanyl and its even more powerful analogs are all made with chemical precursors and catalysts that are so common that they’re beyond effective control. (See the NIH PubChem entries for fentanyl and carfentanil for details.) The precursors are also easily manufactured with even more common precursors. The formulas are public. Importantly, in contrast to the meth manufacturing process, which requires massive amounts of chemicals in order to meet annual demand, a year’s supply of fentanyl sufficient to meet North American demand requires only a few tons of ingredients. Carfentanil- 50 to 100 times stronger by weight than fentanyl- requires only a small fraction of that amount for its manufacture. Carfentanil is active at a dose of 1 microgram. One millionth of a gram. The recent reports by police of being poisoned by skin contact with fentanyl have been receiving some ridicule in some quarters. I don’t happen to find it that funny, even if some of the reports have proved to be exaggerated reactions. It’s good to know that it’s unlikely for someone to absorb enough fentanyl to kill them simply by skin contact with a small amount of the substance. But carfentanil is 100 times as powerful, and approximately 100 times less funny.
See the chart at the bottom of the page. If fentanyl is the endgame for opioid interdiction, carfentanil is potentially checkmate.
Shutting down the border is not the answer for a substance that’s as easily smuggled through the mails as fentanyl and its analogs. If we’re going to stop the dying, we need to allow some expanded means of addict maintenance. And I don’t mean clean injection sites that allow street addicts to bring their cartel-marketed supplies and shoot up in the vicinity of caregivers equipped to revive them with naloxone in the event of an overdose. Yes, that “saves lives”, from day to day- but as a harm reduction response, it’s absurd. There are some objective criteria for successfully dealing with this public health crisis: 1) alternatives to street supplied opioids; 2) alternatives to unsafe ingestion methods (especially hypodermic syringes, which are inherently hazardous waste when discarded, particularly when done so carelessly, or by littering); 3) alternatives to consigning addicts to the status of criminalized pariahs who find themselves unable to live in any situation that doesn’t include continual access to an illicit retail opioid outlet- run by criminals, inherently, that’s part of the implicit rules- and its associated social milieu.
If you want to save opioid addicts, you have to meet them where they are. That shouldn’t have to mean meeting them in a formerly public park where they show up to get high on their cartel-sourced narcotics and then go off shoplift the goods to fence for their next high, cop a nod, and sleep behind a dumpster. Degraded street addicts aren’t themselves. There’s no hope of most of them finding the actual person they used to be without stabilizing them and re-acquainting them with the world of people who aren’t obsessed with scoring and getting loaded, foredoomed to live on a timeline horizon of future plans that extends no farther than a few hours, or minutes. Most addicts require stabilizing- not sick, not desperate, not terminally insecure about basic survival requirements- before the prospect of living without chemical endorphin agonists is even imaginable to them. We need to enable an array of addict maintenance options that allow addicts controlled access to opioids. Not just Abstention or Death. The addicts supporting the underground market in fentanyl are already stuck between that choice. They’ve made their decision: rather than acceding to a demand from outside for total sobriety forever, they’re taking their chances with Death.
From Wikipedia, the comparative equianalgesic chart- estimated equivalent pain relief (i.e., effective dose) per amount of a given substance by weight, using 10mg oral morphine as the baseline of measurement. The number in the first column is strength of a substance, in ratio to the morphine equivalent; the number in the second column is the effective dose by weight. Weight is given in milligrams, “mg”, or as micrograms- 1/1000 milligram-abbreviated “µg” , also sometimes referred to as “gamma”. (“Micrograms” is also abbreviated as “mcg”- not to be confused with “mg”, or milligrams. One microgram is one-millionth of a gram. I repeat this measure because it’s so easily confused with the more common measurement of dose strength, the milligram.)
Note that the baseline of comparison- morphine- is said to be active in a dose of 10mg orally, 3.3mg IV. Heroin is active at 2.5mg IV. Fentanyl is active at 1/10 of a milligram, or 100 micrograms (aka 100µg). The Carfentanil equivalent of 10mg oral morphine is 1 microgram (1µg).
