By Mafalda Pardal, Elle Wadsworth, Beau Kilmer

Potent synthetic opioids, illegally produced, are starting to emerge in Europe. Considering the damaging harms caused by the opioid crisis in North America, which has led to a substantial surge in overdose deaths, it is crucial that European leaders understand the challenges associated with synthetic opioids. In this Perspective, we present and discuss the current situation in Europe concerning synthetic opioids, and draw on earlier and ongoing crises involving this group of substances to reflect on likely challenges ahead and ways to improve preparedness.

Santa Monica, CA: RAND, 2024. 20p.

By Stacey Mckenna

Overdose deaths have skyrocketed across the United States in recent years, increasing by 622 percent between 2000 and 2020, with more than 112,000 lives lost in 2023. This crisis has been largely driven by the proliferation of potent synthetic opioids such as illicitly manufactured fentanyl, which is up to 50 times stronger than heroin.

The opioid antagonist, naloxone, is an especially important harm reduction tool in this landscape. Naloxone binds to opioid receptors in the brain, preventing other opioids, such as fentanyl or heroin, from binding to and activating them. The U.S. Food and Drug Administration (FDA) first approved the medication for the reversal of opioid overdoses in 1971. When administered in a timely manner, naloxone can restore breathing within minutes and successfully reverse 75 to 100 percent of overdoses.

Consequently, lawmakers and government agencies across the country have taken steps to improve access to naloxone. State legislatures have passed laws providing immunity to laypeople who administer the medication, authorized statewide standing orders to facilitate prescription-free pharmacy access, and purchased naloxone in bulk for direct distribution and to pass along to community-based organizations and first responders. Last year, the FDA approved intranasal naloxone products for over-the-counter sale for the first time.

However, with novel, increasingly potent synthetic opioids dominating the illicit supply, some medical experts worry that naloxone as we know it is simply not good enough anymore. In fact, in 2021, the FDA approved both higher-dose naloxone products and new, longer-lasting opioid antidotes, and some government agencies have begun purchasing these products for distribution in their communities.

This policy study aims to inform legislators and public health decision-makers about how high-dose naloxone fits into federal, state, and local efforts to combat the opioid overdose crisis. We examine the research on naloxone efficacy—in laboratory and medical settings and in the real world—and assess potential drawbacks associated with alternatives to standard-dose naloxone.

R Street Shorts No. 135 Washington, DC: R Street, 2024. 10p.

By The Congressional Budget Office

The United States has been experiencing an opioid crisis since the mid-1990s, and opioids have had a significant effect on public health and on the nation’s economic and social outcomes. In this report, the Congressional Budget Office examines the consequences and timeline of the crisis, the contributing factors and federal responses to it, and the effects of the coronavirus pandemic on the crisis.

Deaths. More than 500,000 opioid-involved deaths have occurred since 2000, and the United States has the world’s highest number of opioid-involved deaths per capita. Although federal funding to address the opioid crisis has increased in recent years, opioid overdose mortality has increased as well. Deaths from opioid-involved overdoses were among the leading causes of death in 2020.

Health and Other Effects. The use and misuse of opioids can result in serious health effects: People with certain harmful behaviors that result from opioid misuse—such as an increase in the amount and frequency of opioid use or failure to fulfill major responsibilities at work, home, or school—have opioid use disorder (OUD), which can affect people’s participation in the labor force and their ability to care for their children. Treatment for OUD is used far less than behavioral health professionals recommend.

Changes Over Time. The opioid crisis has occurred in waves distinguished by the different types of opioids involved in overdose deaths and the use of opioids in combination with other drugs.

Contributing Factors. A rise in opioid prescribing, changes in illegal opioid markets, and greater demand for opioids due to worsening economic and social conditions for certain populations are key contributors to the crisis.

Federal Laws. Between 2016 and 2018, three laws enacted in response to the crisis aimed to lower the demand for and supply of opioids and to reduce their harm. The funding in those laws complemented annual appropriations to agencies tasked with responding to substance use disorder, including opioid use disorder.

The Crisis After the Enactment of the Laws and During the Pandemic. Opioid-involved deaths continued to increase after the laws were enacted—initially more slowly than in preceding years but then more rapidly during the pandemic. Opioid misuse increased during the pandemic as people experienced worsened mental health, more social isolation, greater job losses, and reduced access to treatment. In addition, the use of more potent synthetic opioids led to a sharp increase in overdose deaths. The pandemic and other factors have made it difficult to isolate the effect of the laws on the opioid crisis.

Washington, DC: CBO, 2022. 38p.

Edited by Bradley D. Stein, Beau Kilmer, Jirka Taylor, Mary E. Vaiana

Opioids play an outsized role in America's drug problems, but they also play a critically important role in medicine. Thus, they deserve special attention. Illegally manufactured opioids (such as fentanyl) are involved in a majority of U.S. drug overdoses, but the problems are broader and deeper than drug fatalities. Depending on the drugs involved, there can be myriad physical and mental health consequences associated with having a substance use disorder. And it is not just those using drugs who suffer. Substance use and related behaviors can significantly affect individuals' families, friends, employers, and wider communities. Efforts to address problems related to opioids are insufficient and sometimes contradictory. In this 600-page report, researchers provide a nuanced assessment of America's opioid ecosystem, highlighting how leveraging system interactions can reduce addiction, overdose, suffering, and other harms. At the core of the opioid ecosystem are the individuals who use opioids and their families. Researchers also include chapters on ten major components of the opioid ecosystem: substance use disorder treatment, harm reduction, medical care, the criminal legal system, illegal supply and supply control, first responders, the child welfare system, income support and homeless services, employment, and education.

Santa Monica, CA: RAND, 2023. 618p.

By Laura M. Maruschak, Todd D. Minton, and Zhen Zeng

This report provides data on the screening and treatment practices of local jail jurisdictions for opioid use disorder. It presents the prevalence of screenings among jail admissions and rates of positive screenings. It describes the prevalence of jail admissions receiving medication for opioid withdrawal and of the confined population receiving medication-assisted treatment for opioid use disorder. The report also details differences by jail characteristics and state rates of opioid overdose deaths.

  Washington, DC: U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics, 2023. 25p.  

By Marie Gottschalk

A closer examination of media coverage, the response of law enforcement and policy makers, the legislative record, and the availability of proven, highquality treatments for substance abuse casts doubt on claims that the country pivoted toward public health and harm-reduction strategies to address the opioid crisis because its victims were disproportionately white people. Law enforcement solutions directed at people who use and sell street drugs continue to far outpace public health and harm-reduction strategies. Government support for expanding access to proven treatments for opioid use disorder that save and rebuild lives remains paltry given the scale of this public health catastrophe. And although the rhetoric has been somewhat more sympathetic, at times it rivals the excesses of the crack era. The article examines the various phases of the opioid crisis as they have unfolded over the past 25 years; related geographic and racial shifts in overdose fatalities with each new phase; media coverage of the crisis; the federal government’s response, including by the US Congress and presidents from George H.W. Bush to Joe Biden; punitive developments at the state and local levels; and the country’s poor record on prevention and making effective treatment widely available for people with substance use disorder.

Annual Review of Criminology, 2023. 6:363–98 . 39p.

By Jeffrey A. Singer and Trevor Burrus

Fifty‐one years after President Richard M. Nixon declared a “war on drugs,” overdose deaths from illicit drug use have climbed to record levels. Last November, the Centers for Disease Control and Prevention reported 100,000 overdose deaths for the 12‐month period ending in April 2021, a 28.5 percent increase over the year before. Nearly 76,000 of those deaths were opioid related, and 83 percent of opioid‐related deaths involved illicit fentanyl.

Fentanyl is a highly potent opioid—about 50 times stronger than heroin—that can easily cause overdoses, particularly if users don’t know if it is in their drug supply or how much. Over the past decade, drug traffickers have increasingly preferred fentanyl because of its compact size. The smuggler’s preference for higher potency drugs is a manifestation of the “iron law of prohibition,” and it is almost the entire reason fentanyl has poisoned the American drug supply. The iron law of prohibition states that, all things being equal, as enforcement ramps up, smugglers prefer higher potency forms of a drug for the same reason those who sneak alcohol into a football game prefer hard alcohol in flasks to 12‐packs of beer. The lethal logic of the iron law of prohibition means that we cannot enforce our way out of the opioid crisis. And if fentanyl smugglers bexcome somehow easy to catch, there’s always carfentanil, which is about 100 times more potent than fentanyl and has already been showing up in America’s drug supply.

Washington, DC: Cato Institute, 2022. 10p.

By Itzel De Haro Lopez

The global increase in the demand for avocados has attracted the attention of rent-seeking criminal organizations in Mexico. As a result, farmers and packing houses have become the targets of drug trafficking organizations (DTOs). This paper aims to answer whether declining drug revenues have motivated cartels to target licit businesses, such as avocado farms, rather than continue specializing in the production and distribution of illicit drugs. To do this, I exploit exogenous variation in the demand for pure heroin in the U.S. between 2011 and 2019. In particular, I use the introduction of Fentanyl in the U.S. as a proxy for the reduction in the demand for pure heroin in Mexico to answer whether this led to an increase in homicides and cartel presence in avocado- and poppy-growing municipalities. Using municipal level data, I show that the decrease in the demand for heroin increased homicide rates (including those of agricultural workers) in avocado-growing municipalities. I find no evidence of higher cartel presence in these municipalities, suggesting that, while DTOs do not seem to be moving into these municipalities, they have become more violent toward civilians. Furthermore, I find that the fall in the demand for heroin led to a decrease in cartel presence and homicide rates in poppy-growing municipalities. Overall, this paper provides evidence of inter-sector spillovers resulting from drug demand changes.

Madison, WI: Department of Agricultural and Applied Economics, University of Wisconsin–Madison: 2022. 58p. Working Paper.

By Alabama Appleseed

Every year from 2012-2020, Alabama ranked first in the nation for opioid prescriptions per capita. Since 2014, the opioid addiction has claimed the lives of nearly 7,000 Alabama residents who died by overdose, and disrupted the lives of countless more.

Since 2017, many state agencies have collaborated successfully via the Alabama Opioid Overdose and Addiction Council to chart a better path. The state has invested in treatment and peer specialists and reframed addiction as a public health issue, not a moral failing. For people who manage to steer clear of jails and prisons, things are starting to look up. 

But the combination of harsh criminal laws, the nation’s highest opioid prescription rate, and Alabama’s under-resourced jails and violent and dysfunctional prisons mean that many of the people who need treatment most are not getting it. Instead, they are dying preventable deaths in record numbers. Something must change.

Montgomery, AL: Alabama Appleseed Center for Law and Justice, 2022. 58p.

By Len Engel, Erin Farley, and John Tilley

The drug overdose epidemic that swept through the United States over the past decade commanded the attention of public health providers, researchers, criminal justice practitioners, and policymakers at the federal, state, and local levels. Because of its severity and associated mortality rates, the epidemic became a priority among leaders across multiple sectors. As collaboration across these sectors matured, researchers and practitioners began to develop evidence-informed strategies to slow the spread of the epidemic. But the progress that was underway appears to have abruptly stopped when the COVID-19 pandemic emerged and fundamentally altered many aspects of American life.

Washington, DC: Council on Criminal Justice, 2020. 11p.

By Diana S. Kim

"Though today opiates are highly controlled substances and generally viewed as menaces to society, the opium trade was once licit and profitable, both for merchants and for the governments to which they paid taxes. During the late nineteenth century, British and French colonies in Southeast Asia drew up to fifty percent of their revenue from taxes on opium consumption. Given its profitability and European rulers' strenuous defence of opium as an integral part of managing an empire, how did both attitudes toward and laws about opium shift so dramatically by the mid-twentieth century? This book argues against the conventional understanding that opium prohibition was enacted as part of a wave of liberal humanitarianism or because doctors awoke to its dangers to users' wellbeing, and instead offers a more complex story. In examining the opium's fall from grace throughout British and French colonies in Southeast Asia from the 1860s to the 1940s, Diana Kim combines extensive archival research with her training in political science. This book reveals the key role minor colonial administrators played in the abolition process. Local administrators were players in intellectual debates and decision-making processes concerning opium, and the knowledge they produced-their records and observations-influenced the empire's revenue policies. The author's analysis of these processes challenges notions that states implement policies based on maximizing their revenue. By observing how opium prohibition was implemented differently and at different times across the region, Kim argues against the idea that the push for prohibition came from the metropole. Further, she reflects on the lasting legacies of prohibition and the implications for present-day politics and public regulation of vice crimes and illicit markets, making a statement about how vice is defined and how its regulation affects processes of state formation, colonial and otherwise"

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  region, Kim argues against the idea that the push for prohibition came from the metropole. Further, she reflects on the lasting legacies of prohibition and the implications for present-day politics and public regulation of vice crimes and illicit markets, making a statement about how vice is defined and how its regulation affects processes of state formation, colonial and otherwise”

Princeton, NJ: Princeton University Press, 2020. 336p.

By David Macdonald

Afghanistan is the world's largest producer of opium and heroin. This book explores the devastating impact that the drugs trade has had on the Afghan people. Author David Macdonald has worked as a drugs advisor to the UN. Based on his extensive experience, this book breaks down the myths surrounding the cultivation and consumption of drugs, providing a detailed analysis of the history of drug use within the country. He examines the impact of over 25 years of continuous conflict, and shows how poverty and instability has led to an increase in drugs consumption. He also considers the recent rise in the use of pharmaceutical drugs, resulting in dangerous chemical cocktails and analyses the effect of Afghanistan's drug trade on neighbouring countries.

London: Ann Arbor, MI: Pluto Press, 2007. 320p.

By Pierre-Arnaud Chouvy

Known to the Greeks as 'opos' or 'opion', as 'afiun' in Persian and Arabic, and 'fuyung' in Chinese, opium is at once a palliative and a poison. Its exotic origins, its literary associations, and the properties that are, often erroneously, attributed to it have ensured an ongoing air of mystery. Pierre-Arnaud Chouvy reveals the long and fascinating history of a powerful and addictive drug and explores the changing fortunes of the modern-day illicit opium trade, especially in the remote regions of Asia. He answers key questions: Why have anti-drug policies failed despite four decades of increasing effort? And what are the shortcomings and limitations of forced eradication, alternative development, "silver bullets," and other quick fixes? In answering these questions, Chouvy draws upon geography, anthropology, politics, and development studies. He shows that the history of opium production is unexpectedly linked to the history of Afghanistan. A compelling account of a narcotic as old as humanity, Opium offers powerful insights into the complex politics and economics of the poppy in the world today.

Cambridge, MA: Harvard University Press, 2010. 272p.

By W. Travis Hanes III and Frank Sanello

In this tragic and powerful story, the two Opium Wars of 1839–1842 and 1856–1860 between Britain and China are recounted for the first time through the eyes of the Chinese as well as the Imperial West. Opium entered China during the Middle Ages when Arab traders brought it into China for medicinal purposes. As it took hold as a recreational drug, opium wrought havoc on Chinese society. By the early nineteenth century, 90 percent of the Emperor’s court and the majority of the army were opium addicts.Britain was also a nation addicted-to tea, grown in China, and paid for with profits made from the opium trade. When China tried to ban the use of the drug and bar its Western smugglers from its gates, England decided to fight to keep open China’s ports for its importation. England, the superpower of its time, managed to do so in two wars, resulting in a drug-induced devastation of the Chinese people that would last 150 years.In this page-turning, dramatic and colorful history, The Opium Wars responds to past, biased Western accounts by representing the neglected Chinese version of the story and showing how the wars stand as one of the monumental clashes between the cultures of East and West.

Naperville, IL: Sourcebooks, 2004.  352p.

By Maia Dolphin-Krute

An epidemic is a feeling set within time as much as it is a matter of statistics and epidemiology: it is the feeling of many of us in the same desperate place at the same desperate time. Opioid epidemic thus names a present moment — at once historic and historical — centered on the substance of opioids as much as it names the urgency of all of us who are currently in proximity to these substances. What is the relationship between these historic and historical moments, the present moment, the history of pharmacological capitalism, and a set of repeated neurological activities, as well as human loss and desire, that has fueled the exponential rise in the rates of opioid use and abuse between 2000-2018? Opioids: Addiction, Narrative, Freedom is an auto-ethnography written from deep within—biologically within—this opioid epidemic. Tracing opioids around and through the bodies, governmental, and medical structures they are moving and being moved through, Opioids is an examination of what it means to live within an environment saturated with a substance of deep economic, political, neuroscientific, and pharmacological implications. From exploring media coverage of the epidemic and emerging medical narratives of addiction to detailing the legal inscription of differences between “pain patients” and people addicted to drugs, Opioids consistently asks: what is it like to live within an epidemic? What forms of freedom become possible when continually modulated by our physical experiences of the material proximities of an epidemic? How do you live with something for a long time?

Brooklyn, NY: Punctum Books, 2018. 192p.

By Carl A. Trocki

What is the link between opium, imperialism and capitalism? Was the British Empire built on opium? And what can the nineteenth-century drug trade tell us about the Asian heroin traffic of today? Carl A. Trocki answers all these questions in his fascinating history of the great imperial drug trade of the nineteenth century: the British-Indian opium trade. The book brings together for the first time nearly fifty years of scholarship and research on opium trafficking, addiction, and other studies on drugs, the economy and human society. Opium, Empire and the Global Political Economy raises provocative questions about the historical relationship between opium, capitalism and European imperialism in Asia. Opium needs to be considered in its role as an economic commodity, and seen in the context of other "drug'' trades, including sugar, tea, alcohol and tobacco. Trocki's evidence convincingly suggests that European imperialism, and the creation of a global economy, relied heavily on these great drug trades. All reoriented labor, land and capital in the service of commodity production and usually involved "industrial" modes of production. In order to serve these trades, systems of international exchange - such as shipping lines and banking - were brought into existence. They created the first great mass consumer markets, first in Europe and then, with opium, in Asia. Opium, Trocki argues, facilitated important elements in the European imperial advance through Asia, and was equally a fiscal support for virtually all of the new Asian states.

Abingdon, Oxon, UK; New York: Routledge, 1999. 224p.

By Salvador Astucia

After President John F. Kennedy was killed in 1963, America became deeply involved in the Vietnam War. Within a few short years, heroin addiction in America reached epidemic proportions. In the background, Israel expanded its borders by force and became a colonial empire ruling a nation of hostile Palestinian subjects. This book reveals how Israel exploited the Western powers’ long history of opium trafficking as a means of toppling the young American president.

Gaithersburg, MD: Ravening Wolf Publishing Company. 2003. 416p.

By Roderic Broadhurst, Matthew Ball and Harshit Trivedi

A snapshot of the sale of fentanyl and its analogues across several popular darknet markets between 2 January and 27 March 2019 reveals the amount, types and physical forms available. Of the 127,541 unique drug listings identified, 13,135 were opioids (10.3% of all drugs), of which 1,118 (0.876% of all drugs) were fentanyl or its analogues. Between 27.3 and 39.3 kilograms of fentanyl and its derivatives were available over the period. The average price of fentanyl was A$99 per gram, while carfentanil was A$26.8 per gram. The shipping methods, cross-market operations and product specialisation of the 303 active fentanyl vendors on these darknet markets are also described.

Canberra: Australian Institute of Criminology, 2020. 14p.

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.