Fri, Dec

How to Save 50,000 Lives a Year


GELFAND’S WORLD - Meet the Press is one way to find out what is on peoples' minds in the Washington, D.C. area, which is to say, what current topic will be the subject of panic and rage among political candidates. Taking into account that the writers' strike is still going on, we nevertheless had a session of Meet the Press over the weekend. The current topic was the drug Fentanyl, with the undercurrent being how to reduce the death toll in this country.

It's traditional to start such discussions with comments about "When I was a kid," but strangely enough, it actually is appropriate in this instance. Back in the old days, according to the experts on Meet the Press, the annual death toll from heroin was about six thousand. That seems like a lot, particularly if you think of these as preventable deaths, but the current fentanyl death toll is now in excess of one-hundred thousand. So at the current rate, fentanyl deaths over the next decade will be approximately the same as the total deaths from Covid-19 during its pandemic phase. Fentanyl kills more Americans than car accidents, whereas the old school heroin death rate was only a fraction.

Interestingly, aging heroin addicts who were doing reasonably well are now dying because the heroin supply is being cut with fentanyl. Keep that in mind as we proceed.

The rest of the Meet the Press discussion was geopolitical, which is my way of describing the increasingly strained, pained, and furtive attempts to talk about the fact that fentanyl is being exported into the U.S. from northern Mexico. A few Republican leaders overtly support sending the U.S. Army into the area to fight the drug cartels. Those from other sides of the political fence talk about diplomatic efforts to reach across to the Mexican government, although in almost the same breath they point out that the northern section is beyond control of the central government.

Thus the supply side of the equation is talked about, but not in any optimistic sense, and one might say that it isn't even a serious sort of conversation.

The conversation then moves to therapy and helping people to get off their addictions. One person referred to the standard replacement drugs for heroin such as methadone. For various reasons, this doesn't seem to be all that good a solution, although it has been used for a few heroin addicts in the past.

There are one or two more factual tidbits which may be of interest before I get into the main discussion. The first is that there is a reason that so much fentanyl gets made and exported into this country. If you look up the Wikipedia site for Fentanyl, you will find that it is a pretty simple chemical, without a lot of bridges or other crosslinks. Here is what it looks like:


    [fentanyl chemical structure]


Wikipedia even provides descriptive summaries of 4 different ways to synthesize fentanyl out of simple precursors. It's no secret and it's cheap.

So manufacturers in India and China are flooding the northern Mexico market with fentanyl precursors, and the rest is American demand.

There's one other point which I'd like to make here, but it involves a bit of biology and a little bit of chemistry. If you don't want to follow, just skip the next paragraph.

The brain and other parts of the body are made of cells, and human cells cover themselves with lots of protein molecules on their outer membranes. These proteins do various things such as helping cells to import sugar, but one important thing that some of them do is to act as sensors. Some sense the level of insulin, and some sense the presence of the body's own endorphins. What is of interest to the biochemist is that some of these sensors can be fooled by artificial, synthetic substances. Thus the whole opioid family. So let's imagine, say, the mu-opiod receptor, and imagine the effect on it when you eat opium or morphine or heroin. The overall effect depends on whether the synthetic compound can stick to the sensor, how well it holds on, and how long it stays stuck. The longer and stronger that synthetic compound sticks, the more effective it is. There are even numerical estimates of how effective the synthetic can bind and activate the opioid receptor. This is the source of the numbers you hear on tv shows, that fentanyl is 50 times stronger than heroin. It's the same cellular receptor that is affected; it's just that some chemicals stick better and work more strongly. The other thing about fentanyl is that it has certain advantages in treating some medical problems. For example, it can be effective for terminal cancer patients.

Now let's get to the crux of the matter. Meet the Press hosted the U.S. senators from Ohio, one being Republican and the other being a Democrat. They tended to say fairly similar things, which involved getting control over the import of fentanyl and offering some sort of treatment for users. By the way, why Ohio? Answer: It's a pretty good example for the fentanyl explosion in the midwest, and the midwest is one of the worst places for overdose deaths in recent years.

An obvious approach and telling the truth

One more tidbit. Back several decades, the editors of Consumer Reports looked at drug use and the enforcement of the drug laws. Their book was called Licit and Illicit Drugs, and you can still find it here.  As you will notice, it originally came out in 1973. At the time, the cocaine epidemic had not yet occurred, and widespread use of fentanyl was a long way off.

But in reading that book, way back then, there were certain observations -- lessons, you might say -- that stood out. The war on drugs was (using my own terminology here) essentially a game of Whac-a-Mole. You hit the mole as it pops up from the machine, and as soon as that mole disappears, another one pops up.

The difference is that in the war on drugs, every time you whac one mole, a bigger mole pops up.

The book was, even back then, prophetic about the use of old drugs and the appearance of new drugs. At the time, the authorities were trying to suppress the use of amphetamine. As the authors pointed out, low level amphetamine tablets were available by prescription, were not dangerous, and were considered useful by people who wanted a little help in staying awake during periods of stress. The prediction one would have made at the time was that -- as legal amphetamine usage was curtailed -- we would begin to see increased use of illegal amphetamine and of cocaine. These predictions have been borne out again and again.

Outlaw one thing, and something else pops up in its place.

One other point: A hundred years ago or thereabouts, raw opium was used by ingestion and inhalation. But with the suppression of opium, other opioids started to be used. Heroin was among the strongest, but it was sold on the street in highly diluted form, so the buyer would receive a tangible amount of powder, although it actually contained only a small amount of the actual product. Here's the punchline. As the authors of Licit and Illicit Drugs pointed out, the heroin user was actually getting a dose which was, ounce for ounce, equivalent to the same mass of opium. The whole point of heroin production was to create a highly compact version of opium that was easier to smuggle.

So now in fentanyl we have a sort of super-heroin. It's incredibly compact in terms of getting it across a border, and it works pretty much the same way, other than the fact that it has to be diluted quite a bit more, lest it kill the user outright.

And one last point, which you might think of as the libertarian argument. People have their emotional and physical needs. Imagine trying to deal with constant fear, as you might endure with some sort of mental processing disorder. Or try to imagine the depression that comes from the loss of self-worth as the industry you used to work in is disappearing. We're talking about the industrial midwest in its economic decline.

And one other point. Heroin and marijuana usage were, at one time, portrayed by the media as largely a minority problem. It turns out they aren't. It is as much a small town and out-of-work and hillbilly problem as it is a minority problem. In brief, people in the midwest and the deep south use drugs to get their kicks and to snuff their suffering the same way that others do.

So one way to reduce the fentanyl death toll is to offer something that is safe and works just as well. The man on Meet the Press who talked about elderly heroin users had the solution, but he would not say it. Pharmaceutically pure morphine and heroin (which is, after all, just the acetylated version of morphine) can be manufactured cheaply, and could, if we were willing to use reason, be sold over the counter in drugstores. Or there could be morphine dispensaries the way we now have marijuana dispensaries. Instead of losing 100,000 people to fentanyl deaths each year, maybe we would see a reduction to 50,000, and then to the original 6000 heroin deaths. And we don't know how many of those original 6000 deaths were actually due to faulty product, and might have been prevented.

Provide a safe product at a cheap price. This is a suggestion that would meet loud and immediate opposition, even though there are plenty of long-term heroin users who survive, and sometimes even stop using. The opposition is generally verbalized as follows: Some person is shown on television, saying, "Drugs killed my brother. Now you want to make it easy for other people's brothers and children to die from drug use. Put a stop to drug sales and save lives!"

The response is a difficult one to make, but has its equal share of truth. No prohibition has been successful. No nation that introduced tobacco ever got rid of it entirely, and the attempt to ban alcohol in the United States speaks for itself. If we were to offer substances for sale that can be used safely, then lots of people would use them safely. Others wouldn't, but right now, there are people who intend to use drugs safely but, due to the effects of a super-potent opioid which can be manufactured for pennies, a lot of them are dying needlessly.

My prediction is that there will be a long, slow, and brutal battle against fentanyl and whatever comes after it, and then whatever comes after that. This is because the war on drugs has been politicized and made ideological. There is an alternative, and it has worked in some places for some people. It may be that addicts will remain as addicts, but as much as possible, let's allow them to try to be productive and useful people who happen to have a substance need.

(Bob Gelfand writes on science, culture, and politics for CityWatch. He can be reached at [email protected].)