Why fentanyl is producing an overdose crisis unlike anything we've ever seen before
Jonathan Caulkins, former advisor to Barack Obama and author of a confidential report to the BC government, says the fentanyl crisis will require a dramatic changes in our response
BC’s toxic drug overdose crisis, now taking the lives of five or six British Columbians a day, began with this simple calculation, according to U.S. drug policy expert Jonathan Caulkins: “Fentanyl cuts heroin dealers’ raw materials costs by more than 99 percent.”
It was a supply side, profit-seeking strategy by drug dealers that drove the production and distribution of fentanyl, Caulkins argues, not a demand side pressure from people with substance use disorders.[1]
”Fentanyl penetrates markets when suppliers embrace it,” he wrote in 2019, as the overdose crisis began its deadly upward trajectory.
Worse, he concluded that “fentanyl does not increase the number of users; it increases the number of deaths among an existing pool of users who use drugs,” a pool constantly replenished, of course, by the factors laid bare in SFU psychologist Bruce Alexander’s famous Rat Park experiment.
The result is a spiralling overdose crisis with no parallel in the history of the drug trade, Caulkins warns, one that will require “innovative approaches, such as creatively disrupting online transactions; implementing supervised consumption sites; piloting the use of novel evidence-based medications, such as heroin-assisted treatment; and encouraging the use of drug content testing technologies.”
In fact, refusal to consider new approaches, even technologies that do not yet exist, “may condemn many people to an early death.”
Some of these novel strategies may form part of a confidential report by Caulkins, apparently now complete, to Provincial Health Officer Bonnie Henry, who retained former advisor to Barack Obama to analyze the “economic costs of safe supply,” a vague term that could mean almost anything.
On the one hand, Caulkins could be considering the potentially very high expenses associated with manufacturing, securing, prescribing and safely distributing a safer fentanyl substititute like diacetylmorphine, or heroin. Or he could be engaging in a cost-benefit analysis of averting fatal or near-fatal overdoses, with their staggering immediate and long-term health care costs.
News of Caulkins’ work for Henry first reached the public in late April, when then BC United frontbencher Elenor Sturko rose in Question Period to demand that Premier David Eby release Caulkins’ “secret report.”
Henry promised to do just that, but so far has not. Sturko, by now a newly minted Conservative Party of BC candidate, was back on social media June 23 repeating her call for Henry, allegedly a “drug legalization advocate,” to release the report. She also repeated her demand for Henry to be fired.
Sturko should be careful what she asks for, because Caulkins’ rigorous research refuses to be hammered into any ideological mould. While critics of harm reduction have celebrated Caulkins’ criticisms of the “destigmatization” of deadly drug use, they have been notably silent about his common sense call to consider unprecedented measures, including new enforcement approaches and opioid substitution programs, to rein in the death rate.
Fentanyl, he warns, now being streamed into the drug supply by criminal networks with global reach, may soon completely replace heroin and other opiates in the illicit drug supply.
In wide-ranging research on the roots of the fentanyl explosion, Caulkins has questioned why this outbreak of fentanyl production has been so devastating when previous efforts failed.
Fentanyl, after all, has been widely used in health care settings for more than half a century, its chemistry is well understood, methods for its manufacture for medical use have been circulated online, and it has turned up, if only briefly, in the US drug supply on several occasions.
Caulkins and his collaborators concluded that earlier efforts to manufacture fentanyl stumbled in the face of more complex chemistry, logistical bottlenecks and successful law enforcement. That began to change in 2014 as fentanyl-driven overdose death rates began to climb in the US Northeast, about the same time BC experienced a similar uptick. (BC’s opioid health emergency was declared in 2016.)
The game-changers were globalization and the internet, which opened the door to direct purchase of fentanyl or precursors from lightly regulated Chinese producers. These factors, combined with much-simplified lab procedures to synthesize the drug, also available online, unlocked the door to mass production. Organized crime quickly created labs on this continent, a process accelerated by the Covid-19 epidemic. Production had simplified to the point where untrained workers could produce reliably potent results.
As the third-largest consumers of opioids in the world, after the US and Germany (which does not have a fentanyl epidemic), hundreds of thousands Canadians were a large and lucrative potential market for the drug trade when governments cracked down on over-prescribing. The chemistry was well-known, the criminal networks were in place, China offered abundant supplies, costs could be cut by 99 percent. The perfect storm broke.
Caulkins’ report will be especially valuable if it opens the debate on enforcement. (As a former RCMP officer, Sturko should welcome this.)
“The transition to fentanyl and other synthetic opioids is driven by suppliers,” Caulkins and his team wrote in 2019, “so it makes sense to consider supply reduction as one piece of a comprehensive effort. Even if supply cannot be eliminated altogether, delaying the entrenchment of fentanyl in a market by even a few years could save hundreds, if not thousands, of lives.”
To that end, Caulkins challenges governments to back police efforts to disrupt supply chains closer to the source, following leads on the dark web, improving regulation of precursors, and improving drug detection technology.
The task is daunting. Caulkins and his colleagues have calculated that it might require just 1,800 one-kilogram packages of fentanyl to supply the entire US heroin market in 2019. An equivalent supply of heroin would weigh 45 tonnes.
Whatever Caulkins concludes in his report to Dr. Henry, he brings a fresh eye and a global perspective. Will the report come out before the election? With voting less than 120 days away, it’s likely the next stop for this “secret report” is the transition binders of the incoming government.
BC dealer’s three-ounce fentanyl stash counts as Newfoundland’s largest-ever seizure
A roaming travelling salesman for BC’s massive toxic drug industry has claimed the dubious distinction of being arrested June 19 with Newfoundland’s largest-ever seizure of fentanyl.
The RCMP and the Royal Newfoundland Constabulary announced June 21 they had arrested 25-year-old Abishake Lohia, who they linked with an organized crime group called BICO (Blood In, Blood Out) from British Columbia. Lokia had recently moved to the hamlet of Steady Brook (pop. 450), a community near the town of Corner Brook.
While miniscule compared to the kilos of fentanyl routinely seized in this province, the arrest confirms that no market is too small for the tireless entrepreneurs of the drug trade.
Overdose deaths in Newfoundland, with a total population around 500,000, doubled last year to 73, of which nine were caused by fentanyl and 11 by alcohol. British Columbia suffered more than 40 deaths per 100,000 residents in 2023 as a result of opioid and stimulant overdoses. Newfoundland and Labrador had only about five per 100,000. Someone, it seems, would like to drive those Newfoundland opioid numbers up.
[1] Jonathan Caulkins’s books, journal articles and opinion pieces are invariably written with collaborators. Quotes attributed to Caulkins in this article are all taken from documents written by Caulkins and others.
Thanks, Derek, I will follow up with Donald. As you probably are aware, I spent time at City Hall with Larry Campbell when Donald was the drug policy advisor. It was all Four Pillars then. I don’t know about moderate enforcement, but the criminology and police types I have spoken to feel the effort is confused and contradictory, so “moderate” may make it sound more intentional than it is. Regards, Geoff
Geoff,
Appreciate your various writings on the overdose crisis, much needed insights and dialogue, but I think you were some generous about the wisdom of the Caulkins contracting (whether Caulkins worked for Mr Obama or not). More info is always better than less, but the apparent framing of the report by the folks who hired Caulkins suggests they gave him a narrow framing of the complexity of the hard drug issues here in BC. I like the 4 pillars approach at least in broad terms rather than focusing heavily on one pillar (and lightly on the other 3 pillars).
You mentioned that maybe Caulkins will say some thing about enforcement....well ya, as he should do about prevention and recovery as well, along with digging into the safe supply and related focus he appears to have been asked to do (but who knows for sure. However, what is an American drug policy and programming expert, after a few months of research up here, going to know about enforcement at a granular level within the BC/Canadian social, policing, legal and political contexts? In a recent summary journal article, Caulkins stated, "We have argued in a number of papers that a modestly enforced prohibition of production and sale [of hard drugs] generates most of the benefits with fewer of the adverse consequences". 'Modestly enforced prohibition', maybe these three words summarize the existing practices re enforcement in BC?
If you want a blog idea, maybe interview Don McPherson, get his perspective re BC substance use and 4 pillars applicability/success/etc today. He's easy to find at SFU.
Derek De Biasio