<!–

–>

October 20, 2022

Dr. Joseph Alton’s recent piece in AT—“What You Need to Know About Fentanyl”—is best represented by his comment, “I’ve known of fentanyl my entire medical career.” He’s a medical preparedness specialist, and in that field, I defer to him. But my career was spent in Anesthesiology, where we don’t know “about” fentanyl, we know it intimately. I have personally administered gallons of the stuff. For that reason, I can pick up the discussion where he left off, which is the “show me the money” issue.

‘); googletag.cmd.push(function () { googletag.display(‘div-gpt-ad-1609268089992-0’); }); }

Anesthesiologists know about all the other opiates. It does not matter whether they are natural (opium, morphine), refined and modified natural (Heroin, Dilaudid), semisynthetic (codeine, hydrocodone, oxycodone), or fully synthetic (meperidine, pentazocine, fentanyl, sufentanil, remifentanil, and so on). If I give a patient an appropriately measured dose of any of those drugs, they will all produce basically the same desired effects and undesired side effects. 

In short, while hair-splitters will argue, the fact is that they’re all basically the same drug. You read that right. Opiates all do the same things. They just do it via different routes of administration and for different durations. Of course, with continued dosing, all sorts of multiple-compartment pathways of distribution and elimination lead to changes in duration, and receptors become tolerant, requiring higher doses.

Now that I’ve impressed you with my knowledge of pharmacodynamics (effects) and pharmacokinetics (uptake, distribution, and elimination), (insert snarky comment here), let’s tackle the question Dr. Alton did not ask: “Why, given that all these drugs cost almost nothing to manufacture, have they made criminals immensely rich?”

Image: Fentanyl from a United States Sentencing Commission publication.

‘); googletag.cmd.push(function () { googletag.display(‘div-gpt-ad-1609270365559-0’); }); }

As Hamlet said, “Ay, there’s the rub.” If heroin and fentanyl are as cheap to make as aspirin (and they are), why aren’t they sold for pennies at your neighborhood pharmacy? If they were, the Mexican drug cartels would go broke, because there wouldn’t be any profit in it. This economic question points us to the Pure Food and Drug Act of 1906 and its descendants. Those laws made possession of opiates for non-medical use a crime. And there are people who want those intoxicants, come Hell or high water.

Roughly a third of the population throughout history has wanted intoxicants. Fermented beverages like beer are universal. Other intoxicants such as marijuana, psilocybin, khat, and coca leaf are nearly as prevalent. The key in all of them is that, as commonly used, they generally provide some sort of buzz, but without causing the inability to function. Overused, all lead to problems.

Opiates can cause a much more profound “high” in some people. This leads to a desire for more. However, continued use causes receptor tolerance, which requires more and more of the drug for the same effect. Before long, this tolerance prevents any high from the drug. All that’s left is the abstinence syndrome, commonly shown in movies as a horrific withdrawal. That may be a bit overblown but still leads the addict to search for more drugs to avoid its unpleasantness.

Only a small fraction of one percent of addicts starts with prescription drugs. The rest are introduced in non-medical locations with the purveyor intending to cause addiction. It is that addiction that finances the Mexican cartels. And those profits can only exist because the drugs are illegal.

When a person wants an intoxicant drug, he realizes that it’s illegal. In turn, that means he must surreptitiously interact with a curbside pharmacist. Since it’s illegal, the pusher demands a high price to compensate him for the chance of arrest and prosecution he’s taking. In economics, that’s a “risk premium.” If the user must pay a high price, he demands higher quality. It’s a vicious cycle that leads to more drug merchants entering the neighborhood. 

When competing criminals appear on the same turf, two outcomes are possible. The first is a turf war, similar to Chicago’s daily sonic footprint. The other is competition to reformulate the drugs to be more attractive to users. This typically involves adding fentanyl to heroin. Heroin is essential because it lasts hours, while fentanyl lasts minutes. The fentanyl can give a “hit” to overcome tolerance while the heroin postpones withdrawal. Both are needed. This creates an economic problem.