America’s Opioid Crisis: Fentanyl and Super Meth - The Fourth Wave | Publius XU (2024)

Contributors: Mallory Bowling, Madison Clore, Abbie Edwards, Andy Hamer,

Patrick Hemmig, Jason Huffman, Declan LeWarn, Jack Micucci, Lucius Overby,

Trevor Tiemeyer, Luke Uhlman, Kennedy Weigel, Seth Workman

Over the last two decades, America’s opioid crisis has created grave social and economic problems that threaten the country. As examined in this article, it began with prescription opioids (first wave) in the 2000s, followed by heroin around 2015 (second wave), then fentanyl and super meth starting around 2020 (third wave), and now fentanyl-laced meth, heroin, and other opioids (fourth wave). Today, fentanyl and super meth are inexpensive to produce, easy to make, hide, and smuggle, and so highly addictive they create a captive market. Moreover, it seems that the war is being lost in spite of extensive efforts by law enforcement to apprehend cartels, producers, and dealers, the judicial system to convict, and social workers to rehabilitate. This article examines the causes, the criminal network, social consequences, enforcement efforts, and possible solutions to America’s opioid crisis. The article draws from the following sources: the seminal work of Sam Quinones, who in his two award-winning books Dreamlandand The Least of Us, chronicles the history of America’s two-decade opioid crisis; the recent book by Peter Schweizer, Blood Money, which details the myriad of international drug enterprises, many in China, that manufactured fentanyl, its analogues, and other synthetic drugs; Luke Smith’s 2021 Publiusarticle, “Examining the Roots of a Crisis: The Creation of an Opiate Market that Continues to Evolve,” that examines the first wave of the opioid crisis. This article also draws from numerous reports from the Drug Enforcement Administration, Center for Disease Control and Prevention, United Nations Office on Drugs and Crime, and the US Department of Justice, as well as US News and World Report, The New York Times, and other periodicals.

Opioid Era in America—our new Gilded Age, where companies dispensed with any moral or ethical concern in the pursuit of making money.

Sam Quinones[1]

Serotoninand dopamineare neurotransmitters, chemical messengers, sent from the body’s neurons to cells and muscles related to bodily functions. Serotonin is essential for regulating emotions. When one’s levels of serotonin are properly balanced, their mood and sense of well-being are more stable. Dopamine, on the other hand, is a neurotransmitter that is responsible for how one experiences pleasure. When one does something enjoyable, the dopamine release tells their brain that this feels good, motivating one to repeat that activity. Healthy dopamine levels can enhance one’s motivation and ability to concentrate. Thus, while serotonin inhibits many forms of impulsive behavior, dopamine enhances it.[2]Human brains have evolved to keep serotonin and dopamine in balance naturally. Dopamine tells us that something better awaits us; serotonin says we have had enough.

Morphine, heroin, opium derivatives, and synthetically opioids, like fentanyl, when introduced to the body, increase dopamine while reducing serotonin. Desire overwhelms moderation and contentment. Furthermore, “dopamine levels don’t diminish when a person uses a drug of abuse. They stay and prod the person to consume more. When the drug is removed, the dopamine plummets far below normal levels, leaving one frantically wanting more. This is part of how cravings are created.”[3]

The body produces opioids naturally but not enough to stop severe or chronic pain. When prescribed and used properly, opiates can mitigate pain, allowing patients to feel and function normally.[4]Opiates are commonly used to treat patients in severe pain from cancer treatment or major surgery. One opiate narcotic painkiller often prescribed by doctors is Oxycodone, which has an immediate painkiller effect when taken. Another painkiller, Oxycontin, was developed in 1995 for those suffering from mild to moderate pain and needing pain relief for a longer period. Oxycontin has a much stronger effect on pain because it has a high concentration of Oxycodone. Medications that have Oxycodone added can relieve pain for between four to six hours, while Oxycontin can relieve pain for about 12 hours.[5]

The addictiveness of opiates dictated a long-standing prescription practice administered by specialists. This practice changed in 1996 when Purdue Pharma introduced a controlled-release version of Oxycontin designed to be less addictive than the instant-release version but equally as effective in relieving pain. This claim became a huge selling point of Purdue Pharma’s advertising campaign of Oxycontin—an advertising campaign that led to a sharp increase in the rate of opioid prescriptions.

From 1996 to 2002, Purdue Pharma’s annual sales of Oxycontin increased from $44.7 million to $1.5 billion (U.S. General Accounting Office Report – Oxycontin). To increase its marketing reach to physicians, Purdue doubled the size of its prescription sales division, creating a division specifically focused on doctors that operated out of hospitals. In 1996, its 300-person sales team had a call list ranging from 33,400 to 44,500 doctors. By 2001, the sales team had grown to 700 representatives with a call list ranging from 70,500 to 94,000 doctors.[6]

As Purdue Pharma began its advertising campaign, the firm began to make greater use of prescriber profiles. For Purdue Pharma, the use of prescriber profiles and its increased sales force helped dramatically expand the marketing of Oxycontin. Purdue also hosted numerous physician symposiums focused on pain management and the effectiveness of Oxycontin. As noted, Purdue’s marketing strategy of Oxycontin was a success. Prescriptions for Oxycontin from primary care physicians was Purdue’s leading source of sales from 1996 to 2002.

The global management and consulting firm McKinseyand Companyrecommended to Purdue Pharma a plan that Purdue referred to as “Evolve to Excellence” (E2E), which aimed at urging doctors to prescribe the pill at higher doses. With McKinsey, Purdue developed the FieldGuide software that allowed the company to target high-prescribing doctors. In a review of thousands of internal McKinsey documents, the New York Timesfound that the firm repeatedly allowed employees who served pharmaceutical companies, including opioid makers, to also consult for the US Food and Drug Administration (FDA)—the drug industry’s primary government regulator. New York Representative Carolyn Maloney, commented that “at the same time the FDA was relying on McKinsey’s advice to ensure drug safety and protect American lives, the firm was also being paid by the very companies fueling the deadly opioid epidemic to help them avoid tougher regulation of these dangerous drugs.”[7]

Unfortunately, problems with Oxycontin abuse began surfacing in 2000 when there was an increase in the number of reports of patients visiting several doctors in hopes of receiving one or multiple prescriptions. In 2002, Oxycontin was cited as one of the leading causes of admittance to rehabilitation clinics in several Appalachian states. The rise in OxyContin abuse, in turn, led to a congressional hearing in 2001 in which officials from Kentucky, Virginia, and West Virginia testified to lawmakers about Oxycontin abuse in their states. In 2003, the United States General Accounting Office (GAO) released a report in which it recommended a new FDA label for Oxycontin and the development of a risk-management plan to lower the abuse of Oxycontin along with a national response to deal with Oxycontin abuse going forward.

By 2010, national awareness of the problems associated with overprescribing opioids — what would later be described as the “first wave of the opioid crisis’’— was growing and led other states to crack down on the clinics operating in their jurisdictions. Along with the closing of pain clinics, state and local law enforcement agencies implemented stricter monitoring methods to track the prescriptions of painkillers and began suspending the medical licenses of doctors found guilty of inappropriate prescriptions. In Ohio, for example, the Governor’s Cabinet Opiate Action Team (GCOAT) was launched in 2011 to combat the state’s prescription opioid abuse. In May of 2011, the governor also signed Ohio House Bill 93, which placed tighter controls and limitations on physicians prescribing opioids. (In 2011, 27 of 136 physicians were targeted in Ohio for inappropriate prescriptions or lenient pain clinic operations.)[8]

In 2004, the West Virginia Attorney General sued Purdue for reimbursement for excessive prescription costs. West Virginia was followed by Kentucky in 2007 when their Attorney General sued Purdue over widespread oxycontin abuse in Appalachia. By January 2019, 36 states had filed suits against Purdue Pharma. Finally, in October 2020, Purdue agreed to an $8 billion settlement, pleaded guilty to three criminal charges, and agreed to reorganize as a public benefit company under a trust that is required to consider American public health.

In 2021, nationwide settlements were reached to resolve all opioid litigation against the three largest pharmaceutical distributors—McKesson, Cardinal Health, and AmerisourceBergen—and against Janssen Pharmaceuticals, Inc. and its parent company Johnson & Johnson. The settlement calls for the distributors to pay up to $21 billion over 18 years, and for Johnson & Johnson to pay an additional $5 billion. In 2022, settlement agreements were announced with three pharmacy chains—CVS, Walgreens, and Walmart—and manufacturers, Allergan and Teva. Teva agreed to pay up to $3.34 billion over 13 years and to provide $1.2 billion of its generic version of the drug Narcan over 10 years; Allergan agreed to pay up to $2.02 billion over seven years, CVS $4.90 billion over 10 years, Walgreens $5.52 billion over 15 years, and Walmart $2.74 billion in 2023.[9][10]In a 2023 settlement, Kroger agreed to pay up to $1.2 billion to states and subdivisions and $36 million to Native Americans.[11] Finally, McKinsey agree to pay approximately $870 million to resolve lawsuits by hundreds of US local governments, school districts, and state Attorneys General.[12]

By all accounts, the concerted efforts in Ohio, Kentucky, Florida, and other states were effective in reversing the increasing trend in prescription-drug overdose. In Ohio, for example, prescription opiates decreased from 45% of all unintentional drug overdoses in 2011 to 22% in 2015. The number of prescriptions for opiates and patients receiving opiates also dropped significantly from 2012 to 2015.

The decline of opioid availability left the large number of people who had developed a prescription-opiate addiction with few options. Many addicts began buying heroin. Narcotics traffickers and drug cartels realized that an illicit market for opioids had already been created and, with demand in place, saw the opportunity to profit from distributing this horrendous substitute. Many people addicted to prescription opiates discovered that they experience a very similar high from using heroin. A 2016 intelligence study by the Drug Enforcement Administration (DEA) reports that nationwide heroin-related deaths more than tripled from 2010 to 2014. In Ohio, the proportion of drug overdoses due to heroin surpassed prescription opiates, and heroin accounted for over 45% of all the unintentional drug overdose deaths from 2013 to 2015.

Unfortunately, while the closing of pill mills, the suspension of medical licenses for inappropriate prescriptions, and state and county suits and judgements against Purdue Pharma reversed the prescription opiate epidemic, it did not stop the increases in the number of opiate overdoses. The rise in heroin death following the prescription crisis led to the “second wave of opioid crisis.”

“The Mexican drug cartels, hardening and seemingly indifferent to human suffering, have a fearful respect for fentanyl, they called it El Diablo, “The Devil.” Peter Schweizer[13]

After declining 4.1% from 2017 to 2018, the Centers for Disease Control and Prevention (CDC) reported an 18% increase in the number of overdose deaths for the preceding 12 months ending in May 2020, with 25 states reporting increases over 20%. West Virginia saw a 32% increase in overdose deaths for that time period compared to the previous year. In Kentucky, deaths climbed by 27% and in Ohio by 16%. Overall, the CDC reported 81,230 drug overdose deaths occurred in the United States in the 12 months ending in May 2020, the largest number of drug overdoses for a 12-month period ever recorded. The CDC report, in turn, identified synthetic opioids linked to illicitly manufactured fentanyl as the primary cause for the increases in overdose deaths. The Ohio Addiction & Recovery Center reported that fentanyl was involved in about 80% of all heroin-related overdose deaths in 2018, 74% of all cocaine-related overdose deaths, and 67% of all methamphetamine-related overdose deaths.[14]

The structures of different opioids share many similarities. Whereas opioids like codeine, oxycodone, and hydromorphone are synthesized by modifying morphine, fentanyl is synthesized by modifying meperidine—a synthetic opioid.[15] Fentanyl was developed in Belgium in 1959 by Dr. Paul Janssenunder a patent held by his company, Janssen Pharmaceutical. In 1961, Janssen Pharmaceuticalwas acquired by Johnson & Johnson. A

hundred times stronger then morphine, the medical profession quickly adopted fentanyl as an effective pain reliever and anesthetic. The FDA approved fentanyl for legal, prescribed use in 1968. The agent was introduced as an anesthetic under the brand name Sublimaze. Prior to fentanyl’s introduction in the late 1960s, anesthesiologists used flammable gas. With fentanyl, patients could now be conscious during surgery, with blood pressure normal. Fentanyl was short-acting and could be reversed quickly with naloxone. People were in and out of it, without lingering aftereffects. By the mid-1990s, the fentanyl patch was developed to manage the chronic pain of cancer patients.[16]

In addition to the Janssen method for synthesizing fentanyl, there are also the Siegfried and Gupta synthesizing methods. The Siegfried method is a simpler technique, requiring five chemical steps compared to Janssen’s seven. The Siegfried formula was first published in the 1990s on the Internet. Starting in 2000, underground chemists began to discover the method, as well as fentanyl’s potency and similarity to heroin. For a time, it would become the leading method to illegally produce fentanyl in both U.S. and foreign secretive laboratories.

The Gupta method requires only two steps to creates fentanyl’s precursor. Fentanyl created using the Gupta method requires only one single vessel, leading to its nickname, the “one-pot method.” The Gupta method is often used by clandestine chemists, often referred to simply as “cooks,” to convert precursors into ANPP, before using that to make fentanyl; or simply getting their hands on ANPP and converting that into fentanyl. The Gupta method is currently considered the most widely used method to produce illicit fentanyl, according to samples analyzed by the DEA’s Fentanyl Profiling Program.[17]

A fentanyl high is similar to that of heroin, but with a shorter duration, making it more addictive. As noted, fentanyl is nearly a hundred times more potent that heroin. Fentanyl can also be smoked, snorted, or injected. Moreover, unlike poppy-derived opiates, fentanyl is cheap to produce since it is entirely synthetic and can be clandestinely manufactured—it requires no farming, cultivation, sunlight, or irrigation. According to a 2019 DEA report, it is "estimated that each fentanyl pill costs only $1.00 to produce and can be resold in the U.S. for at least 10 times as much.”[18]

“Doctors and Big Pharma prepared the battlefield …creating a market for the cartels, who then jumped at the opportunity to own the supply and feed the demand”

Sam Quinones[19]

Since the early 1980s, Chinese triadshave controlled 60% of the heroin smuggled into the U.S. Sam Gor, a major international crime syndicate known as ‘The Company,’ controls between 40% and 70% of the Asia-Pacific methamphetamine market, while also trafficking in heroin, synthetic drugs, and precursor chemicals. The syndicate consists of five different triads: 14K, Bamboo Union, Big Circle Boys, Sun Yee On, and Wo Shing Wo. Itsmost active triads involved in the heroin trade are the 14Kand the Big Circle Gang.[20]Since the 1980s, Chinese officials have allowed the triads and triad-linked businesses to operate. The triads have long been alleged to have connections to the Chinese Communist Party (CCP), often through the CCP’s united front groups. In return for allowing their operation, triad members allegedly help the party by suppressing dissents and protests.[21][22]

When the Janssen patent expired in 1981, fentanyl production and distribution on the black market accelerated. In 1985 Janssen Pharmaceutical (J&J) opened its first Western pharmaceutical factory in China. Janssen’s China venture marked the time when Chinese cartels began to make fentanyl. The street names for fentanyl were “China Girl” or “China White.” Following the first wave of the opioid crisis spurred by the pharmaceuticals, Chinese triad-drug traffickers discovered fentanyl as a new way to profit. It could be produced synthetically, laced with pills and other substances, and distributed in different modes to an already existing network of traffickers and dealers (see Exhibit 1). It could also be sold via the internet.As Peter Schweizer describes in his book, Blood Money:

The low cost of fentanyl also created a myriad of international drug enterprises, many in China, but also in India and the Middle East, that manufactured fentanyl, its analogues, and other synthetic drugs. Many of these operations advertised on the public and dark websites and through encrypted applications like WhatsApp, WeChat, and Wickr. They also distributed their fentanyl, precursors, and other drugs through common air and ground carriers, such as UPS and FedEx, carefully packaged to deceive customs inspectors in places across the U.S. and other countries. In the case of fentanyl, drug dealers would mix the fentanyl they acquire from the cartel network or clandestine drug enterprises with other drugs to make them stronger or to improve low quality drugs. The chemicals were paid for in MoneyGram, Paypal, Alibaba, bank transfers, and most commonly Bitcoin and other cryptocurrencies, which make it difficult for enforcement authorities to follow the money.

In 2006, mixtures of fentanyl with cocaine, heroin, marijuana, and pills caused the first major outbreak of deaths in cities across the U.S. To be handled and sold to users, fentanyl was typically packaged with larger quantities of other powders. Local dealers, in turn, had to mix the powders. It took only a small amount of fentanyl’s potency to get someone high and only a minute amount more to kill someone—the difference was the equivalent of a few grains of salt. To mix the powders, dealers in the beginning of the fentanyl epidemic often used the magic bullet blender. As Sam Quinones notes, “Nothing in the Magic Bullet infomercial, of course, suggests that the Magic Bullet ought to be used to mix synthetic narcotics. Yet that’s just what happened. The tiny dynamo proved an especially poor blender of highly potent fentanyl, contributing to epidemic of fentanyl deaths.”[24]

Exhibit 1: Gordon Jing Gordon Jing was the online moniker of a father, Guanghua Zheng, and son, Fujing Zheng, who ran a major international drug enterprise based in Shanghai. They manufactured and sent kilograms of fentanyl, its analogues, and other synthetic drugs through the mail to two dozen countries and at least thirty-five American states. Videos: · 60 MINUTES: Deadly fentanyl bought online from China being shipped through the mail · Two Chinese nationals charged with operating global opioid and drug manufacturing conspiracy resulting in deaths in Akron

In the late 2000s and 2010s, many people quickly were attracted to vaping as a less harmful alternative to tobacco and as a possible pathway to eliminating tobacco addition. The product was marketed as being less harmful than regular tobacco cigarettes, even though vapes still contain nicotine and nearly 2,000 chemicals—the vast majority of which are unidentifiable. The National Youth Tobacco Survey in 2021 found that two million young people use e-cigarettes. This survey also found that 28% of high school students and 8% of middle school students currently vaped on a daily basis.[25]The significant rise in the popularity of vaping also coincided with the rise in fentanyl-laced vapes, compounding the danger of synthetic drugs. Fox 35 in Orlando, FL reported that in one Florida high school, a student's vape tested positive for fentanyl. Perhaps, the scariest part of the report, though, is that the student was unaware of fentanyl and it dangers. Unfortunately, there were many other overdose victims who also unknowingly smoked vape laced with the fentanyl who were not as fortunate.[26]

The flood of fentanyl distributed through the mail from China launched the first fentanyl crisis. Fentanyl distribution by parcel services, however, was limited. The Chinese cartels found a more economical solution to shipping fentanyl incrementally through the mail by producing it in Mexico, often through clandestine partnerships with the Mexican Cartels. According to Schweizer:

TheSinaloa Cartelis the largest drug trafficking organization in the world. According to the US Attorney General, from 1990 to 2008, this Cartel was responsible for importing and distributing 200 tons of cocaine and heroin in the U.S. In 2010, the Cartel also discovered the market opportunity for fentanyl by purchasing fentanyl precursors from the Chinese triads to produce fentanyl and then smuggle it north through its network of dealers. The second most powerful drug cartel in Mexico is the Jalisco New Generation Cartel(CJNG). This cartel is believed to have over 100 meth labs throughout the country and generate over $14 billion per year.[28]The Mexican government consider CJNG to be the most dangerous criminal organization in Mexico. From 2018 to 2020, the Armed Conflict Location & Event Data Projectreported that CJNG engaged in 298 acts of gang-related violence, more than any other cartel during that period.[29]By 2020, U.S. counter-drug officials considered CJNG its biggest criminal drug threat, and Mexico's former security commissioner called the group "the most urgent threat to Mexico's national security".[30]

In May 2019, China's government banned the production and sale of fentanyl and many of its variants. According to a National Public Radio (NPR) investigation, to circumvent this ban, Chinese vendors began marketing fentanyl analogues and the precursor chemicals used to make fentanyl, shipping them directly to customers in the U.S. and Europe, as well as to the Mexican cartels. The analogues are compounds that are only a few chemical steps away from fentanyl. Synthetic opioid vendors shield themselves behind China’s legitimate pharmaceuticals sector.[31] Infobae, a Mexican media outlet, identified sixty-four Chinese companies that were major suppliers to the Sinaloa Cartel and CJNG in Mexico.[32] Moreover, 90% of the fentanyl precursors and analogues produced in China are shipped to international terminals in Manzanillo, Mexico.[33]The ports are owned and operated by Hutchison Holdings, which is largely owned by the triad-linked tycoon Li Ka-shing. Hutchison also owns the railroad terminals that transport goods to Central Mexico.[34]The northern regions of Baja California, Sinaloa, and Sonora have been named the ‘Golden Triangle’ for fentanyl production and transferring. The region distributes fentanyl as raw fentanyl powder and counterfeit pills pressed with fentanyl and by trafficking cocaine, heroin, meth, and marijuana cut with fentanyl. San Diego and Arizona are currently major conduits for fentanyl trafficking in the U.S.[35]