tv Fentanyls Role in the Opioid Epidemic CSPAN September 15, 2019 9:01pm-9:41pm EDT
on capitol hill about the opioid epidemic. experts discuss the trends in fatal overdoses in the u.s., and the challenges policymakers face while working to decrease fat no sentineld -- for no -- and -- fentanyl and opioid-related deaths. >> thank you. my name is bryce. i'm here with beau. and i'd like to introduce dr. p reuter and taylor, who collaborated on this cover has of report. in addition, we would like to acknowledge the fact we dedicated this work to mark, who recently passed away, one of the major mentors in drug policy, who thought innovatively when it comes to drug policy. yes, it isfentanyl, right now the driving force
behind over doors -- overdose deaths in the united states. to give you brief takeaways in the work, the main key point from this report is basically that the nature and magnitude of the crisis brought on by opioids is unlike a traditional drug epidemic, and we're better thought of as a poisoning outbreak. if we limit our policy responses to traditional approaches, these will likely be insufficient and will condemn a lot of individuals. to an early grave. two points. this is new and we need to think more innovatively. keep that in mind. the roadmap for this presentation, i'm going to be speaking to what presently is going on, fennel's footprint in the united states, who is being impacted, and what factors are contributing to this crisis.
fentanyl is not new. it's been around for a while. and then i turn it over to about -- to beau. given the history of fentanyl and what we know about drug markets. and he's going to wrap up with what the federal government can do to respond to this. so, we've been working diligently on opioids. we've been putting together many reports on opioid policy. we launched a new initiative trying to understand the ecosystem of opioids. this is not something isolated to a single part of social problems or social policy. it touches on health care, international affairs, trade. we tried to look at whole dynamics around the policy. in this book is the first major initiative from this project. this is the first comprehensive analysis we're aware of.
in it, we look at prior fentanyl outbreaks. where else is it impacting drug markets? and then thinking about what this means going forward into the future. this is the motivator. everyone is aware the overdose crisis is getting worse every year. the difference, many of you know the prescription opioids drove a lot of the overdoses. it's a triple wave phenomenon, the first being prescription opioids. that changed years ago. as we saw heroin overdoses increase in 2011 or so. that was brought on by policies aimed at reducing access to prescription opioids, those types of things may have tribute -- contributed to a rise in heroin use. then we started to see a shift in overdosed death and drug seizures, predominantly fentanyl. that exponential rise and that
pink line is what is driving today's problem. it is an unprecedented jump in overdoses. you can see synthetic overdoses outnumber heroin @2:1. it's been an unprecedented jump and we've never seen something like this before. what is fentanyl? a lot of people have never heard of fentanyl the last 10 years. if you took a poll and you asked about fentanyl, very few would have heard of it. it's been around 60 years. it's used as an anesthetic, very successfully used in clinical settings. i was treating it. it works for like pain, and aesthetics. but that said, this is not a problem of diverted fentanyl. it's a problem of illicitly imported powders from china, mexico, arriving to drug markets in the united states, poisoning
users. that's the key take away. it's not a diverted problem. it's essentially illicit imports. as i mentioned, we've had several prior outbreaks in the united states, going back to 1979, the first one we could document. there's a difference between what happened before and now. the first aspect of this print -- difference, in terms of location, in prior outbreaks, these were localized to an urban market, one or two different cities, chicago, detroit, couple places in california. that's not the case today. there is geographical variation. this is not isolated to a single city or market. this is spreading across entire states. the duration, prior outbreaks were much shorter. only one lasted longer than two years. today, we're going on six years and there doesn't appear to be an end in sight.
the chemicals involved were different. prior outbreaks traditionally involved fentanyl, smattering of analogs here and there, a few others. that's not the case today. fentanyl still dominates, but we're seeing many more analogs, including highly potent analogs. animalanil was an tranquilizer and is now showing up in drug markets. ohio was hit hard by carfentanil. that wasn't the case in prior outbreaks. it was basically fentanyl, a few analogs, but today is a hodgepodge of chemicals. the sources were different, as well. under prior outbreaks, with the exception of one, they were all domestic outbreaks, and a lab somewhere. it was eventually identified and shut down. not the case today. it's pretty much imported from labs in china. there are also places in mexico
city importing precursors from china and smuggling it across the border. and then distribution is different. if you look at whose distribute in fentanyl, in prior outbreaks, it was fairly limited. these chemists could make fentanyl, but they couldn't distribute it into illicit markets. that's not the case today. basically, any individual can easily obtain a substantial amount of fentanyl online just from the comfort of his or her own basement, i never have to leave his home, come into contact with illicit operators or drug trafficking organizations. you can import the products and distributed downstream, especially where the opioid use is endemic. it's a new challenge for law enforcement. the distribution matters, as well. even if an individual had the wherewithal to synthesize, it was limited because he maybe didn't have the wherewithal to distributed downstream.
as i said, the problem is bad. deaths are way up, but it's still concentrated. this is not a national problem yet. and i should note the states in great do not have good death reporting's, so we dropped them from this analysis. they have the death analysis, but they don't know the overdose reports. the problem here, still concentrated in appalachia, new england, the upper midwest. it's not out west yet. there are early indications from san francisco, data from phoenix showing seizures are up. there are early indications it's starting to infiltrate west, but it's not yet entrenched. some of the policy considerations, how do we help areas swamped in fentanyl? how do we prevent fentanyl becoming entrenched in opioid markets like san francisco, seattle, portland, which have major heroin markets? that said, this problem could
get worse before it gets better. just thinking about untapped markets. the key take away, today's overdose crisis is different from prior crises. bys is different -- driven -- it's much cheaper. users aren't asking for fentanyl . they are often taking steps to avoid coming into contact with fentanyl. that may change over time. fentanyl has displaced heroin in new hampshire. over time, users may become accustomed. but they are actually trying to avoid it. this is different. suppliers are making the decision to move to fentanyl, not users. with that, i will turn it over to talk about some of these futures. you, we explained it to have insights why this problem accelerated the past five or six years. we spent a lot of time looking at how these problems developed
in other countries. we also spent trying to help the readers understand how cheap this is. it's hard to get good information about retail prices, but we look at import prices and make adjustments for potency, the price of a heroin is at least 100 times more expensive than fentanyl. that's a conservative estimate. you can understand why suppliers, why it's so attractive to get access to fentanyl and use that to cut the drug to increase their profits. based on these factors, we identified at least four different scenarios for what the future of synthetic opioids could look like in the united states. the first would be flash and receipt. as bryce indicated, we had a series of outbreaks that didn't necessarily last. there have also been small outbreaks in europe. so in theory, this actually is a possibility. the second option is that we kind of continue with the status quo, where synthetic opioids are
largely mixed with heroin or they're used to make counterfeit pills, oxycodone, or used make counterfeit xanax. one of the issues here is whether or not the fentanyl or other synthetics could get mixed in to stimulants, cocaine and meth impediment. set -- methamphetamine. some of you may be asking why would suppliers be mixing fentanyl in and potentially killing their clients? that is a really good question. but we are seeing this in some places. in fact, there is an analysis looking at the retail level cocaine seizures in ohio. i think this was 2017. and although seizures, at least 20% have some trace of fentanyl. it's not entirely clear whether this was an inadvertent mixing or whether it was intentional, but this is something to pay attention to. a third scenario is the synthetic opioids could replace
heroin. that's what we're beginning to see in new hampshire. you can buy a bag of heroin, but oftentimes there's no heroin in the back. it's going to be fentanyl and other powders. in estonia, when they made the move from heroin to fentanyl, they ended up never going back. it's really the only mature fentanyl market we have in the euro dish in the world -- in the world, and they have the highest overdose deaths in europe. and the final option, coexisting the markets. we saw this in sweden a little bit, where it was a nasal spray for fentanyl. the folks using that weren't necessarily the individuals using heroin. the way to think about this, we have these different scenarios, and it largely depends on a number of factors. are they going to prefer fentanyl? what is going to happen to retail prices? policy could shape what ends up,
how this plays out. lookinging at this and at things are beginning to spread west of the mississippi, as bryce said, we're now hearing more about fentanyl in center cisco, more seizures in seattle -- in san francisco, more seizures in seattle, it's probably going to get worse before it gets better. so, what can the federal government do? first of all, in places already swamped with fentanyl, we have to consider new approaches. number two, we need to get creative about disrupting supply. three, we need to improve monitoring and surveillance. this is in a traditional drug epidemic so we can't treat it like one. in the report, we don't make specific aussie recommendations or do a full -- policy recommendations or do a full cost analysis. because it will depend on which
jurisdiction because of resources they have. but we tried to make it clear, providing more access to an arcane or naloxone, this is not going to solve the problem. we need to think creatively about getting people out of these markets and reducing exposure to these opioids. we offer a number of examples of this thinking. i think there are seven countries where they will actually prescribe pharmaceutical grade heroin to people who have tried methadone multiple times, but are still using heroin. there have been trials of this. results are very good in terms of it resume dissing -- reducing consumption of street based heroin. there's also evidence indicating they can reduce crime and potentially produce health outcomes. at the federal level, this is something we can do trials. even though heroin is a schedule one drug, meaning doctors can't
describe it, -- prescribe it, we can do research on it. also, the federal government could make it easier for localities to experiment with other options, whether it be allowance of fentanyl test strips or supervising construction. -- consumption. there's a lot of discussion about setting up supervised consumption sites. people take the drugs they purchase off the seats -- streets, walk into the facility, have access to clean needles, and they will have a medical official so if they do overdose, they can implement naloxone. philadelphia is pushing this, san francisco. but the department of justice is arguing these consumption sites would violate the substances act. there's a court case going on in philadelphia right now. from a federal perspective, there are a couple things. you could pass a law explicitly
excluding consumption sites from the csa if you want to let localities experiment with this. or you can pass a budget rider saying it could not be used to supervise these sites. that was done with medical cannabis. but it doesn't necessarily require legislation. after colorado legalized cannabis, it was 2013 the department of justice released a memo saying this is still a legal under federal law, but if you follow certain guidelines, we're not going to make going after you a priority. you can imagine the same thing with consumption sites. as long as there's a memorandum of understanding, it's x feet away from schools, maybe a strong research component, you can imagine setting up guidelines and saying if you follow the, you're not an enforcement priority. there are options.
getting creative about disrupting supply, this is important. we have to be clear. we're not going to be able to get rid of a supply anytime soon. that said, the chart bryce showed you, where it hasn't hit hard in the west, if we could just delay the entrenchment of fentanyl and other opioids west of the mississippi, even if only for a couple years, you could save thousands of lives. you need to figure out how to do that. we make it clear in the report a number of jurisdictions, the way they're attacking this is increasing sanctions for low-level sellers. there's absolutely no evidence suggesting this will make a difference. the people selling at the lower levels don't even know what sin the package. -- once in the package. -- what's in the package. you can google this. so hacking these sites, creating
fake sites, doing something to create distrust in the market, that might help delay some of this, especially as it moves west. also, getting creative about setting up some sort of prize between the department of homeland security, they have something like this, where they tried to get new ideas about how they can detect synthetic opioids in international mail. this is the type of ingenuity we need. this isn't a seven-figure problem. you can imagine putting much more money into getting more ideas. you can also do this with other technologies. other ways we may be able to neutralize fentanyl and other certain powders. we need to start thinking creatively. i do like this idea of the opioid detection challenge, but we need to put more money into these endeavors. finally, we need to be improving monitoring and surveillance. if we look at how much money we invested during the aids, hiv
crisis, it was an honest. even today, we're still spending hundreds of millions a year on hiv surveillance. what's happening in the united states, we're cutting some of the best programs we have for understanding the opioid problem. we have to change direction on this. the low hanging fruit, there's a lot of labs and medical examiners, they don't have the technologies to detect the fentanyl. this wouldn't be hard to remedy. another way to think about monitoring this problem is using wastewater testing. this has been popular in europe for quite some time. you can test the sewage and look at the metabolites and get a better understanding of what is being consumed in these areas in real time. europe has embraced this for years. australia has started to take this on. they released a report, they were looking at urban and rural areas. and they found between 2017 and
2018, metabolites for fentanyl and other opioids doubled. over the course of a year. this is not an expensive approach at all. this would be easy to implement. it would be useful west of the mississippi to help jurisdictions to allow them to get a better understanding of when these hit the market. the other piece of this, in terms of surveillance and monitoring, is we need to think about the drug abuse monitoring program. this was the best source of information we had about understanding drug markets. where they interview were focused on individuals who were in jail. so this was for research purposes. they would ask individuals who are in the jails about the drug market histories, how much they paid for the drugs, what drugs they were using. it had nothing to do with our cases. there was a rich assessment of what was happening in the market. at the end of the interview,
they would ask if they wanted to take a drug test for analysis. almost all of them agreed. it had nothing to do with cases. this was a rich research to understand what drugs are being used. it also use that as your analysis results to get a better understanding of what is being consumed. this is a program that ramped up in the early 2000's. two 2003, there were focused on 40 different counties across the united states. there were plans to increase it to 75 counties. in 2003, it got cut. it was funded by the department of justice. it got cut. they realized it was important not only for surveillance, but analyzing the size of drug markets. in 2007, they were able to cobble enough money to bring it back in 10 counties, not the 40 from before. 10 counties for a couple years, went down to five counties, and then cut in 2013. in 2013, bryce showed you that
chart, fentanyl deaths are skyrocketing. at this point, we're losing one of the best data sources we have. like i said, this is not an extensive system. bringing back some version of this could really help us get a better understanding of what happening, what people are purchasing. also, we have those urinalysis results so we can understand when these synthetics will hit certain markets. in terms of concluding thoughts, even though we're talking outside the box thinking, we can't abandon prevention and treatment. we should be doubling down. when we talk about prevention, we don't have to create scare campaigns. fentanyl is scary enough. also, with respect to treatment, treatment and demand need to be able. for people who wanted, they should get access. it's not just getting people in the door. we also have to make sure we're providing the treatment
necessary to keep people engaged to prevent relapse. if we continue to limit our responses to the traditional approaches, this is not sufficient. it may condemn many people to early deaths. i'm hoping as your grappling with this, please consider us as a resource as you learn new ideas and what is being done in other countries. because we really want to help. we look forward to your questions and comments. [applause] >> can you describe what heroin treatment looks like? just like naloxone? question, about what this heroin treatment look like? this has been something implemented in six or seven countries now. they had it in the netherlands, switzerland for about 20 years. as i said, this is four
individuals who have heroin use disorder, and its typically for people who have been using heroin for quite some time. they've tried methadone, other treatments multiple times, but they are still injecting heroin. and there have been a number of randomized, controlled trials, where they've done studies. they get a group of people who want to stop. half of them will be assigned to the heroin-assisted treatment, which involves going into a facility to her three times a day and injecting under medical supervision. that your treatment condition. your controlled condition is methadone. there's strong evidence suggesting those assigned randomly reduce their consumption of heroin. there's also evidence it reduces crime and improves health outcomes. if you think about it, this makes sense. there are a lot of people who have been using heroin on longtime. you often spend a lot of time
trying to get the money to get the drugs, not everyone. sometimes they are putting themselves in situations where they are more likely to be victimized. what this does is stabilize their lives. they go in, they don't have to be hustling to get the money, and it's interesting. in some of these places, they want to stay on heroin forever. in other cases, individuals in this, after their lives have been stabilized, maybe i want to try methadone. maybe i want to get off this. it's interesting. if you're into it, we published a different report that came out in december, 2018. after we did that, there was a new report that came out of zurich, switzerland. this study looked at everyone who is receiving some type of medication for their disorder. the vast majority were receiving methadone. some were receiving slow release morphine. only 12% were receiving heroin
assistant treatment. if you offer this, it's not like everyone wants to get involved. we seen this in other places. it could be different in a world with fentanyl, right? so, the evidence is very solid on this. whether or not we see this same results in the united states is a different question. in those places where lies are stabilized, it makes them easier to take advantage of various resources. most of these places have universal health care. in parts of the united states, we don't have that safety net, nor as strong. it's not entirely clear whether you see those benefits. on the other hand, fentanyl wasn't an issue. we should be trying to do these trials in at least a few places to assess cost and benefits and see if this makes sense. this isn't a silver bullet. this isn't a first or second line defense. but in some of these places where fentanyl is entrenched, if
you could move these individuals, we could be saving lives. curious aboutt your opinion of the history of addiction in this country. those illicitgest drugs have been stable since 2002. i know some people have issued with that data. but if you look at germany, they increased opioid prescribing and they saw a reduction in death rates. i'm curious about your opinion on the relationship between death rates in this country and addiction, and whether prescribing has led to that and whether allowing more access to prescription grade opioids could possibly undercut demand for black market drugs and fentanyl exposure. there's definitely a correlation with access and outcomes. we do see that the more we do
provide these substances, especially in loose, unregulated system, you did see these outcomes associated with addiction, and so on, overdose. i'm not sure about germany. i haven't looked at that. i know looking at the numbers from the national survey of drug use and health, those numbers are a little shaky. opportunity to get on my soapbox here. this is the co-author, professor peter, this is the work he's been doing for some time. this gets back to this issue of monitoring and surveillance. we cut this program, which is really useful not only for monitoring what is useful different places, but what is assess the size of different markets. we would actually understand and have good information about the number of people are using, what substances they are using.
administerar, they the national drug use and health. in terms of substance use, it's a good source of information if you want to learn about alcohol consumption, tobacco. when you're talking about heroin, methamphetamine, and cocaine, it's not as useful. we ran the numbers. we did the work in the obama administration and this administration, as well. if you were to use the national survey of drug use and how this made the total number of people who use heroin on a near daily i think that, would suggest it's about 60,000 people. we know the real number was closer to a million. this is important. peter has been doing great work on this. your hearing people talk about 2 million people who suffered from opioid use disorder.
isthe extent that mr. missing more of the heroin users. we think it's at least 3 million. i think if we want to get a better assessment of what is happening in terms of trends and addiction and also heavy use and recognition use, it's useful. but bringing back this program could really help us get better information. mention i heard you manufactured -- at the beginning of the panel. but from one a lot of people are observing, a lot of overdose deaths are related to people who tried to quit substances that cut fentanyl, and they relapsed. and when they relapsed is when a lot of people are using their lives -- losing their lives. how would you suggest we improve programs to help people from avoiding certain relapses
associated with cut with fentanyl? a lot of people are trying to quit. and when they relapse, which is very normal, is when a lot of people are losing their lives. it's not that they don't stop and they overdose. --n they try to stop, drug-related deaths. bryce: like i said, this should be thought more of as a poisoning phenomenon. the case in point, xanax. this acts on a different receptor in the brain. if you're someone who recognizes -- regularly uses it and buys it off the street, that's a huge problem because you may not have opioid tolerance at all. you're at high risk for overdose. the solution is to increase transparency in those markets. test strips might be useful. if you want to avoid fentanyl at all costs, a test strip would be an easy way to make sure the drug you purchased off the street does not contain
fentanyl. it may not be good in markets that are swamped by fentanyl, and heroin users. if everything contains fentanyl, knowing it contains fentanyl helps. what you need to do is quantify how much, and there is no employable tests to quantify. but going back to the relapse component of your question, that is an important point. we need to create better wraparound services so an individual that goes in and out of jail and can't get access to opioid substitution therapy like morphine or methadone, we have to make sure they are getting the medications so when they come out, they haven't lost their tolerance, they buy their regular dose. we need to do a better job the individuals do not relapse, at least maintain on other opioid therapy. beau: it would be useful to make sure they have these medications available in jails and prisons.
how is it being imported? [indiscernible] arriving in the united states, illicitly? there are two main streams. principally from china, directly by the male or cargo containers. dhl,through fedex careers, express consignment carriers. in addition, a good portion is coming from the border of mexico. drug trafficking organizations are starting to turn away from heroin to synthetic opioids and then tracking those over the border. we don't know how much is coming by other -- either stream, but you do see the bulk weight, a lot of it is coming from mexico. but a lot of it is impure, about 5% pure. in contrast, a product arriving direct through mail, very pure.
the stuff from china is 95% pure. after adjusting for purity, about 75% of what is seized is coming from china. those chains -- trends might be changing. but it might be moving to cargo. you have any data on the economic impact? beau: we haven't gotten those estimates. not just looking at the synthetics, but you here the number is half a trillion, and even those numbers are missing certain components. one of the things we're doing at 're really now, wer'r trying to think of this as an ecosystem. getting ais is also better picture of the full cost associated with this. when those analyses are often
done, a lot of the focus is on the individual, what it means in terms of paying for treatment, health care implications, labor market. but it's also important, thinking about the cost of over we would use disorder or any substance use disorder, how it affects families, how it affects those individuals, the stress on them, what it means for family structure. that's harder to calculate. whatever number you see is probably too low. that's what we're focusing on right now, trying to get a better handle. for theirso means family and other loved ones. question because i have heard from doctors, veterinarians and human doctors, saying the shortage of fentanyl and having a hard time finding enough to give to their patients for pain management.
and we know there's a ton on the street. but it seems the government is making it harder and u.s. manufacturers are cutting back from making it because they are afraid. how do we figure out a way to balance that so it still can be used for what it was meant to be used in the medical profession? bryce: that's a tricky balance. washington post had a story this week, looking at cutting people off, chronic pain patients from their medication. there's a harm there if you do it too quickly. it is true that the amount of fentanyl according to dea quotas has remained flat. i don't know specifically how much is being distributed, but my guess is a lot of doctors are being fearful of prescribing opioids for pain. there's some justifications for that, but it's a comp look at a problem. we do a bad job at treating pain.
we don't treat it copperhead civilly and people are often given -- comprehensively and people are often given pills. and once we settle individuals with addiction, we're still not treating that will either. -- well either. beau: any other questions? ok, i guess we're going to conclude. we're going to stick around so if you want to chat about opioids or anything else, we're here. thank you. [applause] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org]
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