THEY
have America in a deadly grip. In 2015, the most recent year for which
full statistics are available, 33,091 Americans died from opioid
overdoses, according to the Centres for Disease Control—almost three
times the number who perished in 2002. Nearly as many Americans were
killed by opioids in 2015 as were killed by guns (36,132) or in car
crashes (35,092). In the state of Maryland, which releases more timely
figures, drug-overdose deaths were 62% higher in the first nine months
of 2016 than a year earlier.
The opioid epidemic is quite unlike
past drug plagues. Deaths are highest in the Midwest and north-east,
among middle-aged men, and among whites. Some of the worst-affected
counties are rural. In 2013 a 40-year-old woman walked into a chemist’s
shop in the tiny settlement of Pineville, West Virginia, pulled out a
gun, and demanded pills. Don Cook, a captain in the local sheriff’s
department, says he continues to nab many people for illegally trading
prescription painkillers.
The
epidemic is, in short, concentrated in Donald Trump’s America.
(Commendably, Mr Trump raised the danger of opioids on the campaign
trail; sadly, he has done little since becoming president beyond setting
up a commission.) It has even been argued that the opioid epidemic and
the Trump vote in 2016 are branches of the same tree. Anne Case and
Angus Deaton, both economists at Princeton University, roll opioid
deaths together with alcohol poisonings and suicides into a measure they
call “deaths of despair”. White working-class folk feel particular
anguish, they explain, having suffered wrenching economic and social
change.
As an explanation for the broad trend, that might be
right. Looked at more closely, though, the terrifying rise in opioid
deaths in the past few years seems to have less to do with white
working-class despair and more to do with changing drug markets.
Distinct criminal networks and local drug cultures largely explain why
some parts of America are suffering more than others.
Opioids can
be divided into three broad groups. First, and most notorious, are
legitimate painkillers such as OxyContin. Heavily prescribed from the
1990s, some of these pills were abused by people who defeated their
slow-release mechanisms by crushing and then snorting or injecting them.
The second group consists of powerful synthetic opioids such as
fentanyl and carfentanil. These have legitimate medical uses, but are
often manufactured illicitly and smuggled into America. The third opioid
is heroin, derived from opium poppies, almost all of it illegally.
Until
about 2010 the rise in opioid deaths was driven by the abuse of
legitimate painkillers, which are sometimes called “semi-synthetic”
because they are derived from plants. In the past few years, though,
heroin and synthetic opioids have become bigger threats (see chart 1).
Some addicts have moved from one class of opioid to another. The Drug
Enforcement Administration (DEA) estimates that almost four out of five
new heroin users previously abused prescription drugs.
OxyContin
pills can no longer be crushed as easily, and doctors have become more
wary of prescribing powerful painkillers. As a result, between 2012 and
2016 opioid prescriptions fell by 12%. Heroin can be cheaper and easier
to obtain. According to one narcotics officer in New Hampshire, a
30-milligram prescription pain pill sells for $30 on the street. A whole
gram of heroin can be had for $60-80. Fentanyl
is cheaper still. It is often made in Chinese laboratories and smuggled
into America; some traffickers obtain it through the dark web, an
obscure corner of the internet. Fentanyl is usually added to heroin to
make it more potent or is made into pills, which can resemble
prescription painkillers. Because it is such a powerful drug—at least 50
times stronger than heroin—the smuggling is easy and the potential
profits are huge. One DEA official has explained that a kilogram of
fentanyl from China costs about $3,000-5,000 and can be stretched into
$1.5m in revenue in America. By comparison, a kilogram of heroin
purchased for $6,000 translates to $80,000 on the street.
Yet not
all addicts make the switch from one kind of opioid to another. In West
Virginia, Mr Cook hardly ever encounters heroin—perhaps, he suggests,
because no major highway runs through his patch. Whereas the death rate
from prescription painkillers is more or less the same in America’s four
regions, deaths from heroin and synthetic opioids are high in the
Midwest and north-east, middling in the South and low in the West (see
chart 2). All eight states where police agencies reported 500 or more
encounters with fentanyl in 2015 are east of the Mississippi river.
“Once
a drug gets into a population, it’s very hard to get it out,” explains
Peter Reuter, a drugs specialist at the University of Maryland. “But if
it doesn’t get started, it doesn’t get started.” It is never entirely
clear why a drug catches on in one place but not another. There is,
however, a possible explanation for why heroin and synthetic opioids
have not yet taken off in western states: the heroin market is
different.
Although most heroin enters America from Mexico, there
are really two trafficking routes. Addicts west of the Mississippi
mostly use Mexican brown-powder or black-tar heroin, which is sticky and
viscous, whereas eastern users favour Colombian white-powder heroin.
According to the DEA, in 2014 over 90% of samples classified as South
American heroin were seized east of the Mississippi, while 97% of
Mexican heroin was purchased to the west. The line is blurring—Mexicans
are pushing into the white-powder trade, and black tar is creeping
east—but it still exists.
White-powder heroin looks much like a
crushed pain pill, making it comparatively easy to switch from one to
the other. It is also fairly easy to mix white-powder heroin with a
powder such as fentanyl. Black tar is more distinct and harder to lace
with other substances because of its stickiness and colour; mixing in
white powder can put buyers off. “The lore on the street is: the lighter
in colour brown-powder or black-tar heroin is, the less heroin it has,”
says Jane Maxwell, a researcher at the University of Texas at Austin.
The
West’s distinctive heroin market has probably deterred many painkiller
addicts from trying the drug, and has kept synthetic opioids at bay.
Outbreaks have occurred, though. In just two weeks in 2016, 52 people
overdosed and 14 ultimately died near Sacramento, in California, after
taking counterfeit hydrocodone pills laced with fentanyl. In New Mexico,
fentanyl disguised as black-market oxycodone is thought to have killed
20 people last year. This is a rare case where one should pray that
America stays divided.
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