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Research Questions

  1. What can policymakers learn from U.S. fatal overdose and drug seizure trends?
  2. Why has fentanyl been so unevenly distributed across U.S. states and Canadian provinces?
  3. Why did fentanyl, which was first synthesized 60 years ago, create substantial problems only after 2013?
  4. What is the history of fentanyl outbreaks and why is today's outbreak much worse?
  5. What can be learned from other countries' experiences with synthetic opioids?
  6. What might the future of fentanyl and other synthetic opioids look like in the United States?
  7. What innovative policy options deserve discussion and analysis?
  8. How could surveillance and monitoring of synthetic opioids be improved?

Deaths involving synthetic opioids in the United States increased from roughly 3,000 in 2013 to more than 30,000 in 2018. In fact, synthetic opioids like fentanyl are now involved in twice as many deaths as heroin. This book offers a systematic assessment of the past, present, and possible futures of synthetic opioids in the United States. It is rooted in secondary data analysis, literature reviews, international case studies, and key informant interviews. The goal is to provide decisionmakers, researchers, media outlets, and the public with insights intended to improve their understanding of the synthetic opioid problem and how to respond to it.

The authors conclude that (1) fentanyl and other synthetic opioids are becoming dominant in some parts of the United States and Canada, but remain less common in other parts of these countries; (2) a confluence of factors, including the dissemination of simplified and novel synthesis methods and increasing e-commerce, helps explain the surge in synthetic opioids; (3) much can be learned from other countries' experiences with synthetic opioids; (4) supplier decisions, not user demand, drive the transition to fentanyl; (5) fentanyl's spread is episodically fast and has ratchet-like persistence; (6) synthetic opioids drive up deaths rather than the number of users; (7) problems with synthetic opioids are likely to worsen before they improve, and states west of the Mississippi River must remain vigilant; (8) improving surveillance and monitoring is crucial; and (9) limiting policy responses to existing approaches seems unlikely to reverse this tide.

Key Findings

Fentanyl and other synthetic opioids dominate some regional drug markets in Canada and the eastern United States

  • Deaths involving synthetic opioids in the United States increased from roughly 3,000 in 2013 to more than 30,000 in 2018, but remained concentrated regionally.
  • In some markets, fentanyl is replacing — not just adulterating or supplementing — heroin.

Multiple factors explain the rise of synthetic opioids

  • Supply-side factors — rather than increases in demand — explain fentanyl's spread. These include online dissemination of new and more-efficient synthesis methods, anonymous e-commerce, detection challenges, and poor regulation in China.

The spread of synthetic opioids is driven by supplier decisions, not user demand

  • Synthetic opioids are largely a strategic device for dealers seeking to lower costs or skirt drug laws, not a newly popular drug among users.

There is much to learn from other countries' experiences

  • Problems in parts of Canada are as severe as in the eastern United States, despite substantial differences in drug policy and the delivery of public health and social services.
  • European experiences might offer insights into future trends.

Fentanyl's spread is episodically fast and persistent

  • Once fentanyl gains a foothold, it appears capable of sweeping through a market in a few years.

Synthetic opioids drive up deaths rather than the number of users

  • Fentanyl brought a wave of greater death rather than more users, not only in the United States but also in other affected countries.

Problems with synthetic opioids are likely to get worse before they get better

  • The U.S. synthetic opioid problem is not yet truly national in scope. Some regions west of the Mississippi have been less affected to date. Those areas should be seen as at high risk of a worsening problem.

Recommendations

  • Exposure to synthetic opioids in the United States is now largely concentrated in the Northeast, Midwest, and Appalachia. It is imperative that efforts be made to prevent synthetic opioids from becoming entrenched in parts of the country that have been only moderately affected.
  • Policymakers must innovate in places where synthetic opioids are (or are becoming) entrenched. New approaches to responding to the current crisis should be seriously considered (e.g., creatively disrupting online transactions; supervised consumption sites; novel, evidence-informed treatment modalities, such as heroin-assisted treatment; drug content testing). This is necessitated by the nature and scale of the challenge brought by synthetic opioids, which, in their current forms and methods of distribution, represent a departure from previous crises. Indeed, resolution of this crisis might require approaches or technologies that do not exist today.
  • Governments have a unique responsibility for funding data collection and monitoring of drug use, drug problems, and drug markets. The HIV/AIDS crisis prompted large investments in new data and monitoring systems, such as the National HIV Behavioral Surveillance system. The number of opioid-involved deaths is roughly similar to that at the peak of the HIV/AIDS epidemic, but there has been no comparable investment in improving data infrastructure.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Insights From Mortality and Seizure Data in the United States

  • Chapter Three

    Assessing Explanations for the Recent Rise in Synthetic Opioids

  • Chapter Four

    International Experiences with Synthetic Opioids

  • Chapter Five

    Some Possible Futures for Fentanyl and Other Synthetic Opioids

  • Chapter Six

    Concluding Thoughts

  • Appendix A

    Background Information on Synthetic Opioids

  • Appendix B

    The Economics of Mexican Heroin and Fentanyl

  • Appendix C

    Opportunities for Better Surveillance and Monitoring

  • Appendix D

    Supplemental Information on Data and Methods

  • Appendix E

    Details on Key Informant Interviews

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