By Joseph Pergolizzi , Peter Magnusson , Jo Ann K. LeQuang , Frank Breve

The 'third wave' of the ongoing opioid overdose crisis in the United States (US) is driven in large measure by illicitly manufactured fentanyl (IMF), a highly potent synthetic opioid or an analog developed in clandestine laboratories primarily in China and Mexico. It is smuggled into this country either as IMF or as precursors. The southern border of the US is a frequent point of entry for smuggled IMF and the amounts are increasing year over year. IMF is also sometimes mixed in with other substances to produce counterfeit drugs and dealers as well as end-users may not be aware of IMF in their products. IMF is inexpensive to produce and when mixed with filler materials can be used to cut heroin, vastly expanding profitability. It is an attractive product for smuggling as very tiny amounts can be extremely potent and highly profitable. Drug trafficking over the border also involves the tandem epidemic of money laundering as drugs enter the country and cash payments exit. While drug smuggling in and out of the US (and other nations) has been going on for decades, the patterns are changing. Highly potent and potentially lethal IMF is a dangerous new addition to the illicit drug landscape and one with disastrous consequences. 

Cureus  Open Access Review Article 2021. 11p

By Bryce Pardo, Jirka Taylor, Jonathan P. Caulkins, Beau Kilmer, Peter Reuter, Bradley D. Stein 

  The U.S. opioid crisis worsened dramatically with the arrival of synthetic opioids, such as fentanyl, which are now responsible for tens of thousands of deaths annually. This crisis is far-reaching and even with prompt, targeted responses, many of the problems will persist for decades to come. RAND Corporation researchers have completed numerous opioid-related projects and have more underway for such clients and grantors as the Agency for Healthcare Research and Quality, the Assistant Secretary of Health and Human Services for Planning and Evaluation, the National Institute on Drug Abuse, the White House Office of National Drug Control Policy, and Pew Charitable Trusts. Researchers have advanced an understanding of the dimensions of the problem, some of the causes and consequences, and the effectiveness of different responses. However, no one has yet addressed the full scope of the problems associated with opioid use disorder and overdose deaths. Beginning in late 2018, the RAND Corporation initiated a comprehensive effort to understand the problem and responses to help reverse the tide of the opioid crisis. The project involves dozens of RAND experts in a variety of areas, including drug policy, substance use treatment, health care, public health, criminal justice, child welfare and other social services, education, and employment. In this work, we intend to describe the entire opioid ecosystem, identifying the components of the system and how they interact; establish concepts of success and metrics to gauge progress; and construct a simulation model of large parts of the ecosystem to permit an evaluation of the full effects  of policy responses. We dedicated project resources and communications expertise to ensure that our products and dissemination activities are optimized for reaching our primary intended audiences: policymakers and other critical decision-makers and influencers, including those in the public, private, and nonprofit sectors. The project is ambitious in scope and will not be the last word on the subject, but by tackling the crisis in a comprehensive fashion, it promises to offer a unique and broad perspective in terms of the way the nation understands and responds to this urgent national problem. Ten years ago, few would have predicted that illicitly manufactured synthetic opioids from overseas would sweep through parts of Appalachia, New England, and the Midwest. As drug markets are flooded by fentanyl and other synthetic opioids, policymakers, researchers, and the public are trying to understand what to make of it and how to respond. The synthesis of heroin in the late 19th century displaced morphine and forever changed the opiate landscape, and we might again be standing at the precipice of a new era. Cheap, accessible, and mass-produced synthetic opioids could very well displace heroin, generating important and hard-to-predict consequences. As part of RAND’s project to stem the tide of the opioid crisis, this mixed-methods report offers a systematic assessment of the past, present, and possible futures of fentanyl and other synthetic opioids found in illicit drug markets in the United States. This research is rooted in secondary data analysis, literature and document reviews, international case studies, and key informant interviews. Our goal is to provide local, state, and national decision-makers who are concerned about rising overdose trends with insights that might improve their understanding of and responses to this problem. We also hope to provide new information to other researchers, media sources, and the public, who are contributing to these critical policy discussions  

Santa Monica, CA: RAND, 2019. 265p.

By Kristin M. Tennyson, Charles S. Ray,  Kevin T. Maass  

This report examines the relatively new and emerging problem of fentanyl and fentanyl analogue trafficking. It summarizes the Commission’s related policy work and discusses the continuing policy-making efforts of Congress and the Department of Justice in this area. Finally, the publication presents data about fentanyl and fentanyl analogue offenses since 2005 and provides an in-depth analysis of fiscal year 2019 fentanyl and fentanyl analogue offenses and offenders.

Washington, DC; United States Sentencing Commission, 2021. 60p.

Karen Duke, Helen Gleeson, Susanne MacGregor, Betsy Thom

This article explores the factors contributing to drug-related deaths in English and Welsh prisons between 2015 and 2020. Based on content analysis of all Prison and Probation Ombudsman ‘other non-natural’ fatal incident investigation reports, descriptive statistics were generated. Qualitative analysis explored the circumstances surrounding deaths and key risk factors. Most deaths were of men, whose mean age was 39 years. Drug toxicity was the main factor in causing death, exacerbated by underlying physical health conditions and risk-taking behaviours. A variety of substances were involved. New psychoactive substances became more important over time. A high proportion had recorded histories of substance use and mental illness. During this period, the prison system was under considerable stress creating dangerous environments for drug-related harm. This study highlights the process of complex interaction between substances used, individual characteristics, situational features and the wider environment in explaining drug-related deaths in prisons. Implications for policy and practice are discussed.

J Community Psychol. 2023;1–22

By Jason ElighBy Jason Eligh

Despite the extensive population containment and control measures put into place across the globe in the wake of the COVID-19 pandemic, the flow of cocaine powder from Latin America to global markets appears to have been largely uninterrupted. This is despite the fact that measures to significantly reduce supply have been put in place by the governments of Colombia – a country that is still the primary cultivator of coca – and the United States, the primary progenitor of and ally in the war on drugs.

The markets and supply chains for cocaine, as well as other illicit drugs, have proven to be remarkably resilient in the face of the growing patchwork of restrictions on movement and transport since March 2020 in the wake of the COVID-19 pandemic. The many predictions by experts of supply chain disruption to drug flows and the potentially disruptive impact of this on consumer markets have not come to pass. Cocaine distribution networks and related agents quickly found ways to bypass challenges raised by lockdowns and restrictions. Coca cultivation and potential cocaine production even expanded during the first year of the pandemic, reaching record or near-record levels in the three primary cultivation countries of the Andean production region. 

Geneva: Global Organization Against Transnational Organized Crime, 2022. 64p.

By Michael Lohmuller, Nicole Cook, and Logan Pauley

The illicit synthetic drug networks that fuel the ongoing opioid epidemic in the United States continue to evolve and adapt to changing incentives and pressures, finding innovative ways to exploit technology and increased global interconnectivity. C4ADS investigated these drug supply chains, conducting extensive multilingual analysis of Chinese corporate entities, the clear web, and social media, in order to better understand the methods by which they operate.   

Washington, DC: C4ADS 2020, 45p.

By United States and Rand Corporation

The Commission on Combating Synthetic Opioid Trafficking, established under Section 7221 of the National Defense Authorization Act for Fiscal Year 2020, was charged with examining aspects of the synthetic opioid threat to the United States—specifically, with developing a consensus on a strategic approach to combating the illegal flow of synthetic opioids into the United States. This final report describes items involving the illegal manufacturing and trafficking of synthetic opioids, as well as the deficiencies in countering their production and distribution, and includes action items directed to appropriate executive branch agencies and congressional committees and leadership. Get appendices to the report.

Rand, 2022. 148p.

By Bryce Pardo, Lois M. Davis, Melinda Moore

The opioid overdose crisis has continued to accelerate in recent years because of the arrival of potent synthetic opioids, such as fentanyl and related substances. Although several synthetic opioids have legitimate medical applications, the majority of overdoses are due to illicitly manufactured imports. Researchers from the Homeland Security Operational Analysis Center evaluated publicly available data to better understand the dimensions of the consumption and supply of these substances. They performed four tasks designed to gain insight into this new and quickly evolving phenomenon: (1) They evaluated trends in overdoses across regions and over time. Understanding where overdoses due to synthetic opioids occur provides a rough proxy for where law enforcement should prioritize screening efforts for packages that enter the country destined for such markets. (2) They evaluated the supply of fentanyl and related substances using public data from state and local forensic laboratories that report to national systems. The authors note a relationship between lab exhibits and fatal overdoses across regions and over time. (3) They examined the online markets for synthetic opioids. The team collected quantitative and qualitative data from online marketplaces and vendors to better understand what supply and concealment mechanisms vendors use when shipping product to the United States. (4) They evaluated the adulterants and other bulking agents used in retail distribution. There are limitations to each of these approaches, and the authors provide caveats to interpreting their findings.

Santa Monica, CA: Rand, 2019. 91p.

By Bryce Pardo and Peter Reuter

  The synthetic opioid crisis in North America has increased fatal overdose rates to unprecedented levels within a matter of a few years. It involves new technologies, a new source of supply (the chemical industry in China), and new forms of distribution (the internet and mail). These elements are perhaps even more difficult to suppress than other supply sources from foreign countries. This has led to an assumption that nothing can be learned from prior experience in trying to control drug markets. In this paper, we first explore what might be learned from some notable past successes. We begin by examining a set of episodes in which enforcement against a specific illegal drug market had more than a brief impact on supply, though the enforcement may have caused other harms. Examples include the near-elimination of the quaaludes market in the 1980s and the “heroin drought” in Australia in the early 2000s. Exploring common features of these past successes reveals insights that may reduce the risk of fatal overdose. We then examine the characteristics of fentanyl distribution in detail, noting that taken individually, the

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  differences (such as the low costs of fentanyl production and its distribution by mail) are in fact not so distinctive: it is the combination of many differences that creates the unique threat. In response, authorities need to change priorities in supply control domestically. Prior to the arrival of fentanyl and other synthetic opioids, it was reasonable for police and prosecutors to focus on (1) raising prices and restricting availability to reduce consumption and (2) minimizing the violence and disorder around street markets. Yet today, a more important goal may be to reduce the toxicity of the supply and thus the number of drug overdoses. This paper applies the insights of the “focused deterrence” approach developed by David Kennedy and Mark Kleiman, which involves using multiple levers to attain a specific policy goal. We conclude with some specific suggestions for local and national supply-control agencies— including the need to focus more on regulating rather than reducing markets to minimize harm, and to distinguish between markets not yet swamped by fentanyl or in transition and those where the drug is entrenched. Strategies appropriate in one context may not serve well in another.

Washington, DC: Brookings Institution, 2020. 21p.

By Vanda Felbab-Brown

Synthetic opioids remain the source of the deadliest U.S. drug epidemic ever. Since 1999, drug overdoses have killed approximately 1 million Americans,[1] an overdose lethality that has increased significantly since 2012 when synthetic opioids from China began supplying the U.S. demand for illicit opioids. Even though China placed the entire class of fentanyl-type drugs and two key fentanyl precursors under a controlled regulatory regime in May 2019, it remains the principal (if indirect) source of U.S. fentanyl. Fentanyl scheduling and China’s adoption of stricter mail monitoring has created some deterrence effects. Instead of finished fentanyl being shipped directly to the United States, most smuggling now takes place via Mexico. Mexican criminal groups source fentanyl precursors — and increasingly pre-precursors — from China, and then traffic finished fentanyl from Mexico to the United States. Scheduling of fentanyl and its precursors in China is not sufficient to stem flows to the United States.

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  There is little visibility into China’s enforcement of its fentanyl regulations, but it clearly remains limited. U.S.-China counternarcotics cooperation remains fraught, and from the U.S. perspective inadequate. Rejecting U.S. blame of China for the opioid epidemic and emphasizing U.S. responsibilities for that calamity, Beijing points to its benevolence in anti-drug cooperation. But China’s cooperation with the U.S. in the global counternarcotics campaign has been subordinated to the overall deteriorated geostrategic relationship between the two superpowers. There is little prospect that in the absence of significant warming of the overall U.S.-China bilateral relationship, China would significantly intensify its anti-drug cooperation with the United States. U.S. punitive measures, such as sanctions and drug indictments, are unlikely to change that. Structural characteristics of synthetic drugs, including the ease of developing similar, but not scheduled synthetic drugs and their new precursors — increasingly a wide array of dual-use chemicals — pose immense structural obstacles to controlling supply, irrespective of political will to prohibit and regulate their use and enforce the regulations.

New York: Brennan Center for Justice, 2022. 84p.