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The Business of Opioids

‘Drug Entrepreneurs’: How Federal Drug Policy Fed Appalachia’s Overdose Crisis

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A sign tracks drug overdose deaths in Frederick County, Maryland. Photo: Patrick Madden / WAMU

I remember the first time I heard someone I went to high school with died of a drug overdose.

I hadn’t seen him in a decade and we weren’t necessarily close, he was more of a friend of a friend, someone I hung out with in a large group setting. When I heard he had died, I certainly felt sorrow, but I also wasn’t totally surprised. Not because I knew he was struggling with addiction, rather, growing up in Appalachia, I figured it was only a matter of time before drug addiction did affect someone I knew.

A lot of ink has been spilled about the opioid crisis in Appalachia and other parts of the country. It has even attracted the attention of Hollywood. West-Virginia native Elaine McMillion Sheldon’s documentary Heroin(e) was nominated for an Academy Award, focusing on the efforts of three courageous women reformers attempting to combat the crisis in Huntington, West Virginia, where I went to college. Huntington is an epicenter of sorts for this issue, as its overdose rates tower over the national averages—it has been called the “heroin capital of the world.”

Considered an epidemic by the Center for Disease Control and Prevention (CDC) since 2011, President Trump declared the nation’s rate of opioid overdoses a public health emergency in October 2017. From 2000 to 2015, more than 500,000 people died from a drug overdose.

Most explanations of the crisis pinpoint its origins in the 1990s, when doctors began to prescribe, and in many cases over prescribe, opioids to treat various kinds of pain. This led to dependence and addiction on the part of a number pain patients. Heroin and other synthetic opioids, such as fentanyl and its analogs, eventually entered the picture and exacerbated the issue.

But to gain a fuller understanding of why this happened, we need to go further back to the 1970s and the introduction of drug scheduling under the Controlled Substances Act.

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Vox’s German Lopez has written some of the most comprehensive coverage of the opioid epidemic to date, at least at the national level. He is the one-man author of an entire series for Vox, entitled “Confronting America’s opioid epidemic.” In his telling, the crisis’s origin lies in doctors becoming “increasingly aware of the burdens of pain.” Patients with chronic and difficult-to-manage pain were liberally prescribed opioid painkillers by their doctors, egged on by opportunistic pharmaceutical companies, and eventually the U.S. became the world leader in opioid prescriptions.

This phenomenon has affected the entire country, but rural communities in Appalachia, the Northeast, Midwest and South have been hit the hardest. There is evidence showing opioid abuse is intertwined with low education and limited employment opportunities, which describes the socioeconomics of the communities most affected. Broadly speaking, the less educated are more likely to work in jobs that are physically taxing, causing workplace injuries and other types of chronic health problems, which can lead to an opioid prescription from a doctor.

Eventually, though, prescription painkillers gave way to heroin and fentanyl, and this made things much worse. Some analysts, such as J.J. Rich at the Reason Foundation, pin this shift on the legislative response to overprescription. States made it harder for patients to get painkillers, but sharp increases in opioid deaths continued even as prescription rates go down. As pills became harder to find, patients sought out alternative, and more dangerous, methods of pain management—usually heroin and fentanyl.

Fentanyl is a drug used in anesthesia. It is many times more potent than morphine and reacts with the body in ways similar to heroin. It was first approved for medical use in the U.S. in 1968, and accounted for nearly twice as many overdose deaths as heroin and prescription painkillers in 2017, clocking in at just shy of an estimated 30,000 for the year.

What has made fentanyl so deadly? The answer lies in the informational asymmetries caused by the black market and the unintended consequences of the Controlled Substances Act (CSA) of 1970.

As the numbers show, fentanyl can have lethal effects. This is exacerbated by the black market, because many of the drugs being pushed are designer: analogs that have been chemically modified to avoid classification as illegal under the scheduling criteria of the CSA. But these drugs are often sold under common street names and increasingly are imported from abroad. As a result, users don’t know they are consuming a chemically modified analog, which raises the risk of an adverse biological reaction.

Fentanyl analogs are the result of what economist Audrey Redford calls drug “malnovations,” or a form of innovation that seeks to circumvent the law. The CSA was intended to disseminate information about public health issues surrounding drug use and to create a comprehensive list of drugs, categorized by factors such as accepted medical usage and potential for addiction. The overall goal, of course, was to curb illicit drug consumption.

Drugs are classified by the CSA according to different schedules, based on their chemical makeup. Schedule I drugs are the most restricted because they are potentially the most harmful and have no accepted medical use. Heroin is a schedule I substance (as is marijuana, because the federal government does not recognize any related medical uses, despite evidence to the contrary and many states making it legal for medicinal purposes). Fentanyl is a schedule II drug because it has accepted medical uses. Because scheduling is based on the substance’s chemical structure, individual drugs within a larger family need to be specified and scheduled individually.

Problems with scheduling arise, though, when the fundamental demand for drugs from consumers doesn’t decrease.

“When you create a schedule, if you create a list with different categories, it’s going to change the incentives for dealers who are trying to get illicit drug users the substances that they ultimately want to consume,” Redford, a professor at Western Carolina University, told me in an interview. “Even though there were positive aspects to scheduling, it was not the great leap forward many hoped for because drug entrepreneurs were simply responding to incentives.”

The incentive, in this case, is to avoid scrutiny from the federal government. Analogs and designer drugs are chemically modified by “clandestine chemists,” as Redford calls them, to create a technically legal versions of a previously scheduled drug.

“Even if a drug looks like heroin, reacts like heroin, has the symptoms of heroin, and is sold as ‘heroin’ on the illicit market,” she writes in an academic paper on the topic, “but is chemically different than diacetylmorphine (the chemical name for heroin), then it technically is not the scheduled substance under the CSA.”

Federal officials have typically responded to the proliferation of analogs by scheduling them, as they did with fentanyl and its many analogs in the 1980s.

“Every time fentanyl is scheduled formally, or put on a temporary list to decide if it should be formally scheduled, this tells drug entrepreneurs that ‘we’re not allowed to make that one anymore, so now we have to switch to something else,’” Redford said. “Technically, they aren’t breaking the law and are still able to get consumers a product that is reasonably similar to what they are looking for.”

Serious problems arise when you consider that the amateur chemists who are altering these drugs are exactly that: amateur chemists.

“They might be just chemically manipulating things, but they don’t necessarily know for sure, because they are not pharmaceutical chemists working for an established company,” Redford said. “They don’t have the best knowledge and the resources to test the drug to figure out how it will affect people.”

Dealers are simply trying to outpace law enforcement with chemical modification and are unable to consistently predict potency and other factors that will determine how a consumer will react to it. This has created a scenario where “active drug users are at a greater risk of dying than ever before,” as Jay Butler, director of public health at the Alaska Health Department and Social Services and past president of the Association of State and Territorial Health Officials, has said. Users are determined to feed their addiction, dealers are eager to provide for them, and federal enforcement has unintentionally created an atmosphere where that transaction becomes more dangerous.

Fentanyl and its analogs, such as carfentanil, have played a significant role in the downward spiral of several Appalachian states in the last several years, West Virginia included. In 2017, there were more than 1,000 deaths due to overdose in the state, and nearly 600 of those were fentanyl-related. These are initial numbers, and are likely to rise as more death certificates are analyzed.

The border town of Huntington became the face of the opioid crisis on August 15, 2016, when 28 people overdosed in a single four-hour period. As the city’s fire chief Jan Rader said on Meet the Press in October 2017, “it’s been years” since there was a day without an overdose.

Across the nation, fentanyl is involved in half of daily deaths due to overdose.

***

I understand that many people will have a gut reaction against analyzing this issue from the perspective of “drug entrepreneurs,” and thinking of dealers and addicts as rational actors responding to incentives. It seems crass and inappropriate. But it doesn’t change the underlying reality. Well-intentioned measures that, on their face, seem commonsensical often have unintended and unforeseen consequences that can make things worse.

There are no easy answers. Thousands of people have died and thousands more will in the future if current trends continue. I anxiously await the pang that will come when someone else I knew from my adolescence or college years is among them.

Jerrod A. Laber is a DC-based writer and journalist, and a contributor for Young Voices. His work has been published in the Columbus Dispatch, Washington Examiner, The National Interest, and Arc Digital, among other outlets. He was born and raised in Appalachian Ohio. Follow him on Twitter @JerrodALaber.

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