Opioids are a class of drugs that include heroin and prescription pain relievers such as oxycodone (Oxycontin), hydrocodone (Vicodon), codeine, morphine, fentanyl, methadone, and others. They are used to reduce pain (for example as a form of end-stage cancer treatment) but can also cause intense euphoria or a high which can lead to dependence and addiction. Opioid overdoses cause respiratory arrest, coma, and death. Symptoms include mental confusion and severe sweating and nausea. Fentanyl is assessed to be between 50 and 100 times more potent that heroin or prescription opioids. It can be taken in pure form or used to ‘cut’ or adulterate other typical street drugs such as heroin, cocaine, or prescription pills.
Drug overdose death rate by drug type, United States, 1999 to 2020
Annual number of deaths in the United States from drug overdose per 100,000 people
According to the US Justice Department, “Overdose deaths often result from a user’s unwitting purchase and use of fentanyl when believing he or she is purchasing heroin or prescription pills.” A very small dose of fentanyl - around 2 milligrams - can be fatal to the user. The Justice department adds that fentanyl can now be found in fake tablets, pills, and gel capsules mimicking the look of prescription drugs. Further complicating efforts to control the epidemic is the fact that there are also many fentanyl ‘analogues’ in circulation – synthetic drugs with similar but not identical composition. In November 2021 the independent US-based International Narcotics Control Board said it had identified more than 150 fentanyl-related substances with “no currently known legitimate uses”. The United Nations Office on Drugs and Crime (UNODC) estimates that illicit laboratories could potentially synthesize thousands of other fentanyl analogues.
When President Nixon first spoke about launching a “war on drugs” in 1971, annual overdose deaths in the US stood at 6,771. By 2022 that had multiplied by a factor of 15 to reach 107,375. Of that total, around 70% of the deaths were attributed to fentanyl. The level of concern over the epidemic in the US is acute. A Brookings report in 2019 stated that in the preceding decade over 1m US citizens had died from suicide, drug, or alcohol related deaths. It termed them “deaths of despair” and noted they were most prevalent “in the American heartland, in places where manufacturing and other blue-collar jobs have disappeared”. The report also stated that “the crisis is both demand and supply driven: desperation related to the decline in the quantity and quality of low skilled jobs collides with a market flooded with opioids and other drugs”. The fentanyl crisis is held responsible for what might otherwise appear as a statistical anomaly: the US is the only wealthy country in the world where mortality rates are climbing, rather than falling.
Mortality is rising in the United States
All cause-mortality ages 45-54 for U.S. non-Hispanic whites (USW), U.S. Hispanics (USH), and six comparison countries
Source: Brookings
Some analysts have made an interesting but dark correlation. Expressed as a proportion of the total population, overdose deaths in the United States have now increased to a level comparable with drug violence-related killings in a number of Latin American countries. For example, in 2020, US overdose deaths from “any opioids” totalled 20.1 per 100,000 inhabitants. In the same year Mexican deaths from “intentional homicides” (mainly drug-war related) totalled 29 per 100,000; those in Colombia were 24.3 per 100,000. The comparison highlights the human costs of the illicit drug business at opposite ends of the supply chain.
There is some discussion over the way in which fentanyl addiction may, or may not, spread beyond the United States. The United Nations Office on Drugs and Crime (UNODC) in its World Drug Report 2023, emphasises that synthetic drug production is inherently different from plant-based drugs such as cocaine, heroin, and marijuana. Synthetic drugs can be produced in labs anywhere, anytime, unconstrained by weather conditions or by the need to conceal illicit fields of cultivation from government surveillance aeroplanes or drones. UNODC says this advantage of synthetic drugs has led to a boom in laboratory drug production in the Middle East (mainly captagon) and Africa and Central Asia (tramadol), as well as North America (fentanyl).
But the report also says that there are only small-scale consumer markets for synthetic drugs in South America. These markets trade drugs like MDMA and ketamine (which is used in tusi, a South American synthetic preparation known as ‘pink cocaine’). Fentanyl has only been detected in small quantities in Argentina, Paraguay, and Brazil. A possible reason for this is that fentanyl tends only to appear where there has been a large pre-established opioid market, focused around legal prescriptions and pain relief. UNODC researcher Brice Pardoe told specialised website InSight Crime: “There is not a major heroin market in South America. There is not a major diverted-prescription opioid market in South America. Fentanyl is not really going to show up there to any great extent.”
The story however is different in northern Mexico with its multiple migration, trade, and social connections across the long border with the United States. Fentanyl consumption by heroin users was for example detected in cities like Tijuana from 2007 onwards. There are also indications (discussed below) that pharmacies in border areas are increasingly cutting prescription drugs with fentanyl.
