One short letter’s huge impact on the opioid epidemic

cnn_logo_2449Every day, 91 Americans die from an opioid overdose. Drug overdoses overall — most of them from opioid painkillers and heroin — are the leading cause of accidental death in the US, killing more people than guns or car accidents. In fact, while Americans represent only about 5% of the global population, they consume about 80% of the world’s opioid painkillers. But how did we get to this point?

Many public health experts point to a simple five-sentence letter to the editor published in a 1980 edition of the New England Journal of Medicine. The 101-word letter, titled “Addiction Rare in Patients Treated with Narcotics,” was signed by Jane Porter and Dr. Hershel Jick of Boston University, who said that of their 11,000-plus patients treated with narcotics, there were only four cases of addiction.

And although this letter provided no further evidence and was not a peer-reviewed study, it has often been cited as proof of the safety of prescribing long-term narcotics for chronic pain.
This article is from CNN and you can read the rest of it here.

How can prescription drugs lead to heroin use?

177Mind Your Meds

Two-thirds of teens who report abuse of prescription medicine are getting them from friends, family and acquaintances. Make sure the teens in your life don’t have access to your medicine. Follow these three steps to find out how to monitor, secure and properly dispose of unused and expired prescription and over-the-counter cough medicine in your home.

Step 1: Monitor

Parents are in an influential position to immediately help reduce teen access to prescription medicine because medicine is commonly found in the home. But how aware are you of the quantities that are currently in your home? Think about this: Would you know if some of your pills were missing? From this day forward, make sure you can honestly answer yes.

Start by taking note of how many pills are in each of your prescription bottles or pill packets, and keep track of refills. This goes for your own medicine, as well as for your teens and other members of the household. If you find you need to refill your medicine more often than expected, that could indicate a problem.

If your teen has been prescribed a medicine, be sure you control the medicine, and monitor dosages and refills. You need to be especially vigilant with medicines that are known to be addictive and commonly abused by teens, such as opioidsbenzodiazepines and stimulants.

Make sure your friends, parents of your teen’s friends, neighbors and relatives — especially grandparents — are also aware of the risks. Encourage them to regularly monitor their own medicines in their own homes.

Step 2: Secure

Approach securing your prescriptions the same way you would other valuables in your home, like jewelry or cash. There’s no shame in helping protect those items, and the same holds true for your medicine.

Take prescription medicine out of the medicine cabinet and secure them in a place only you know about. As mentioned previously, if your teen has been prescribed a medicine, be sure you control the medicine and monitor dosages.

If possible, keep all medicines, both prescription and over-the-counter, in a safe place, such as a locked cabinet your teen cannot access. Spread the word to other households that teens may have access to, and encourage them to secure their prescriptions as well.

Step 3: Dispose

Safely disposing of expired or unused medicine is a critical step in helping to protect your teens, your family and home, and decrease the opportunity for your teens or their friends to abuse your medicine. Lake County has a network here.


Lethal Dose Comparison: Heroin v Fentanyl

heroin vs fentaynl

Village of Round Lake Park- Prescription Medication Disposal Program Launches Home Pickup Initiative

RLPCurrently members of the public can dispose of their unwanted and expired prescription medications conveniently and safely at the Round Lake Park Police Department, located at 215 E. Main Street, Round Lake Park IL.

The Police Department’s Prescription Medication Drop Off Disposal Program is available Monday thru Friday from 9 a.m. to 4 p.m. excluding holidays when the station is closed to the public (dates and times subject to change).

Beginning May 1, 2017, the Round Lake Park Police Department will be launching a new prescription medication disposal initiative. Residents that are unable to dispose of prescription medications due to health-related issues or transportation problems can now contact the Police Department by telephone at 847-270-9111, and an available officer will be dispatched to their home to pick up and appropriately dispose of the medications.

The disposal program does not accept illicit drugs or medical waste, including syringes, biological samples, vials, tubes, transdermal patches or over the counter medication. This program is designed to give the public an opportunity to prevent pill abuse and theft by ridding their homes of potentially dangerous expired, unused, and unwanted prescription drugs. Medicines in home cabinets are highly susceptible to misuse and abuse.

Prescription drug abuse in the United States is a significant problem as are the number of accidental poisonings and overdoses due to these medications.

Studies show that a majority of abused prescription drugs are obtained from family and friends, including from home medicine cabinets. Traditional methods for disposing of unused medicines – flushing them down the toilet or throwing them in the trash – have been shown to pose environmental and health hazards.

For more information, please call the Round Park Police Department at; 847-546-7275.

The New Landscape of Opioid Addiction.

“We should all be dead,” said Jonathan Goyer one bright morning in January as he looked across a room filled with dozens of his coworkers and clients. The Anchor Recovery Community Center, which Goyer helps run, occupies the shell of an office building in Pawtucket, Rhode Island. Founded seven years ago, Anchor specializes in “peer-to-peer” counseling for drug addicts. With state help and private grants, Anchor throws everything but the kitchen sink at addiction. It hosts Narcotics Anonymous meetings, cognitive behavioral therapy sessions, art workshops, and personal counseling. It runs a telephone hotline and a hospital outreach program. It has an employment center for connecting newly drug-free people to sympathetic hirers, and banks of computers for those who lack them. And all the people who work here have been in the very pit of addiction—shoplifting to pay for a morning dose, selling their bodies, or dragging out their adult lives in prison. Some have been taken to emergency rooms and “hit” with powerful anti-overdose drugs to bring them back from respiratory failure.

That is how it was with Goyer. His father died of an overdose at forty-one, in 2004. His twenty-nine-year-old brother OD’d and died in 2009. When he was shooting heroin he slept on the floor of a public garage. He would pick up used hypodermic needles if they were new enough that the volume gauges inked on the outside hadn’t been rubbed off with use. He OD’d several times before getting clean in 2013. Now he visits people after overdoses and tells them, “I was right where you’re at.”

There have always been drug addicts in need of help, but the scale of the present wave of heroin and opioid abuse is unprecedented. Fifty-two thousand Americans died of overdoses in 2015—about four times as many as died from gun homicides and half again as many as died in car accidents. Pawtucket is a small place, and yet 5,400 addicts are members at Anchor. Six hundred visit every day. Rhode Island is a small place, too. It has just over a million people. One Brown University epidemiologist estimates that 20,000 of them are opioid addicts—2 percent of the population.

Salisbury, Massachusetts (pop. 8,000), was founded in 1638, and the opium crisis is the worst thing that has ever happened to it. The town lost one young person in the decade-long Vietnam War. It has lost fifteen to heroin in the last two years. Last summer, Huntington, West Virginia (pop. 49,000), saw twenty-eight overdoses in four hours. Episodes like these played a role in the decline in U.S. life expectancy in 2015. The death toll far eclipses those of all previous drug crises.

And yet, after five decades of alarm over threats that were small by comparison, politicians and the media have offered only a muted response. A willingness at least to talk about opioid deaths (among other taboo subjects) surely helped Donald Trump win last November’s election. In his inaugural address, President Trump referred to the drug epidemic (among other problems) as “carnage.” Those who call the word an irresponsible exaggeration are wrong.

Jazz musicians knew what heroin was in the 1950s. Other Americans needed to have it explained to them. Even in the 1960s and 1970s, with bourgeois norms and drug enforcement weakening, heroin lost none of its terrifying underworld associations. People weren’t shooting it at Woodstock. Today, with much of the discourse on drug addiction controlled by medical bureaucrats, it is common to speak of addiction as an “equal-opportunity disease” that can “strike anyone.” While this may be true on the pharmacological level, it was until quite recently a sociological falsehood. In fact, most of the country had powerful moral, social, cultural, and legal immunities against heroin and opiate addiction. For 99 percent of the population, it was an adventure that had to be sought out. That has now changed.

America had built up these immunities through hard experience. At the turn of the nineteenth century, scientists isolated morphine, the active ingredient in opium, and in the 1850s the hypodermic needle was invented. They seemed a godsend in Civil War field hospitals, but many soldiers came home addicted. Zealous doctors prescribed opiates to upper-middle-class women for everything from menstrual cramps to “hysteria.” The “acetylization” of morphine led to the development of heroin. Bayer began marketing it as a cough suppressant in 1898, which made matters worse. The tally of wrecked middle-class families and lives was already high by the time Congress passed the Harrison Narcotics Tax Act in 1914, threatening jail for doctors who prescribed opiates to addicts. Americans had had it with heroin. It took almost a century before drug companies could talk them back into using drugs like it.

If you take too much heroin, your breathing slows until you die. Unfortunately, the drug sets an addictive trap that is sinister and subtle. It provides a euphoria—a feeling of contentment, simplification, and release—which users swear has no equal. Users quickly develop a tolerance, requiring higher and higher amounts to get the same effect. The dosage required to attain the feeling the user originally experienced rises until it is higher than the dosage that will kill him. An addict can get more or less “straight,” but approaching the euphoria he longs for requires walking up to the gates of death. If a heroin addict sees on the news that a user or two has died from an overly strong batch of heroin in some housing project somewhere, his first thought is, “Where is that? That’s the stuff I want.”

Tolerance ebbs as fast as it rises. The most dangerous day for a junkie is not the day he gets arrested, although the withdrawal symptoms—should he not receive medical treatment—are painful and embarrassing, and no picnic for his cellmate, either. But withdrawals are not generally life-threatening, as they are for a hardened alcoholic. The dangerous day comes when the addict is released, for the dosage he had taken comfortably until his arrest two weeks ago may now be enough to kill him.

The best way for a society to avoid the dangers of addictive and dangerous drugs is to severely restrict access to them. That is why, in the twentieth century, powerful opiates and opioids (an opioid is a synthetic drug that mimics opium) were largely taboo—confined to patients with serious cancers, and often to end-of-life care. But two decades ago, a combination of libertarian attitudes about drugs and a massive corporate marketing effort combined to instruct millions of vulnerable people about the blessed relief opioids could bring, if only mulish oldsters in the medical profession could get over their hang-ups and be convinced to prescribe them. One of the rhetorical tactics is now familiar from debates about Islam and terrorism: Industry advocates accused doctors reluctant to prescribe addictive medicines of suffering from “opiophobia.”

In 1996, Purdue Pharmaceuticals brought to market OxyContin, an “extended release” version of the opioid oxycodone. (The “-contin” suffix comes from “continuous.”) The time-release formula meant companies could pack lots of oxycodone into one pill, with less risk of abuse, or so scientists claimed. Purdue did not reckon with the ingenuity of addicts, who by smashing or chewing or dissolving the pills could release the whole narcotic load at once. That is the charitable account of what happened. In 2007, three of Purdue’s executives pled guilty to felony misbranding at the time of the release of OxyContin, and the company paid $600 million in fines. In 2010, Purdue brought out a reformulated OxyContin that was harder to tamper with. Most of Purdue’s revenues still come from OxyContin. In 2015, the Sackler family, the company’s sole owners, suddenly appeared at number sixteen on Forbes magazine’s list of America’s richest families.

Today’s opioid epidemic is, in part, an unintended consequence of the Reagan era. America in the 1980s and 1990s was guided by a coalition of profit-seeking corporations and concerned traditional communities, both of which had felt oppressed by a high-handed government. But whereas Reaganism gave real power to corporations, it gave only rhetorical power to communities. Eventually, when the interests of corporations and communities clashed, the former were in a position to wipe the latter out. The politics of the 1980s wound up enlisting the American middle class in the project of its own dispossession.

OxyContin was only the most commercially successful of many new opioids. At the time, the whole pharmaceutical industry was engaged in a lobbying and public relations effort to restore opioids to the average middle-class family’s pharmacopeia, where they had not been found since before World War I. The American Pain Foundation, which presented itself as an advocate for patients suffering chronic conditions, was revealed by the Washington Post in 2011 to have received 90 percent of its funding from medical companies.

“Pain centers” were endowed. “Chronic pain” became a condition, not just a symptom. The American Pain Society led an advertising campaign calling pain the “fifth vital sign” (after pulse, respiration, blood pressure, and temperature). Certain doctors, notoriously the anesthesiologist Russell Portenoy of the Beth Israel Medical Center, called for more aggressive pain treatment. “We had to destigmatize these drugs,” he later told the Wall Street Journal. A whole generation of doctors was schooled in the new understanding of pain. Patients threatened malpractice suits against doctors who did not prescribe pain medications liberally, and gave them bad marks on the “patient satisfaction” surveys that, in some insurance programs, determine doctor compensation. Today, more than a third of Americans are prescribed painkillers every year.

Very few of them go on to a full-blown addiction. The calamity of the 1990s opioid revolution is not so much that it turned real pain patients into junkies—although that did happen. The calamity is that a broad regulatory and cultural shift released a massive quantity of addictive drugs into the public at large. Once widely available, the supply “found” people susceptible to addiction. A suburban teenager with a lot of curiosity might discover that Grandpa, who just had his knee replaced, kept a bottle of hydrocodone on the bedside table. A construction boss might hand out Vicodin at the beginning of the workday, whether as a remedy for back pain or a perquisite of the job. Pills are dosable—and they don’t require you to use needles and run the risk of getting AIDS. So a person who would never have become a heroin addict in the old days of the opioid taboo could now become the equivalent of one, in a more antiseptic way.

But a shocking number of people wound up with a classic heroin problem anyway. Relaxed taboos and ready supply created a much wider appetite for opioids. Once that happened, heroin turned out to be very competitively priced. Not only that, it is harder to crack down on heavily armed drug gangs that sell it than on the unscrupulous doctors who turned their practices into “pill mills.” Addicts in Maine complain about the rising price of black-market pharmaceutical pills: They have risen far above the dollar-a-milligram that used to constitute a kind of “par” in the drug market. An Oxy 30 will now run you forty-five bucks. But you can shoot heroin when the pills run out, and it will save you money. A lot of money. Heroin started pouring into the eastern United States a decade ago, even before the price of pills began to climb. Since then, its price has fallen further, its purity has risen—and, lately, the number of heroin deaths is rising sharply everywhere. That is because, when we say heroin, we increasingly mean fentanyl.

Fentanyl is an opioid invented in 1959. Its primary use is in transdermal patches given to people for end-of-life care. If you steal a bunch of these, you can make good money with them on the street. Addicts like to suck on them—an extremely dangerous way to get a high. Fentanyl in its usual form is about fifty times as strong as street heroin. But there are many different kinds of fentanyl, so the wallop it packs is not just strong but unpredictable. There is butyrfentanyl, which is about a quarter the strength of ordinary fentanyl. There is acetylfentanyl, which is also somewhat weaker. There is carfentanil, which is 10,000 times as strong as morphine. It is usually used as an animal tranquilizer, although Russian soldiers used an aerosol version to knock out Chechen hostage-takers before their raid on a Moscow theater in 2002. A Chinese laboratory makes its own fentanyl-based animal tranquilizer, W-18, which finds its way into Maine through Canada.

China manufactures a good deal of the fentanyl that comes to the U.S., one of those unanticipated consequences of globalization. The dealers responsible for cutting it by a factor of fifty are unlikely to be trained pharmacists. The cutting lab may consist of one teenager flown up from the Dominican Republic alone in a room with a Cuisinart and a box of starch or paracetamol. It takes considerable skill to distribute the chemicals evenly throughout a package of drugs. Since a shot of heroin involves only the tiniest little pinch of the substance, you might tap into a part of the baggie that is all cutting agent, no drug—in which case you won’t get high. On the other hand, you could get a fentanyl-intensive pinch—in which case you will be found dead soon thereafter with the needle still sticking out of your arm. This is why fentanyl-linked deaths are, in some states, multiplying year on year. The federal CDC has lagged in reporting in recent years, but we can get a hint of the nationwide toll by looking at fentanyl deaths state by state. In Maryland, the first six months of 2015 saw 121 fentanyl deaths. In the first six months of 2016, the figure rose to 446.

Sometimes arrested or hospitalized users are surprised to find that what they thought was heroin was actually fentanyl. But there are addicts who swear they can tell what’s in the barrel of their needles. One in Rhode Island, whom we’ll call Gilberto, says heroin has a pleasant caramel brown tint, like the last sip of Coca-Cola in a glass. Fentanyl is clear. And many addicts claim they can recognize the high. “Fentanyl just hits you. Hard,” Gilberto says. “But it’s got no legs on it. It lasts about two hours. Heroin will hold you.” This makes fentanyl a distinctly inconvenient drug, but many addicts prefer it. All dealers, at least around Rhode Island, describe their heroin as “the fire,” in the same way all chefs describe their ribs as so tender they just fall off the bone.

“I knew we were screwed, as a state and as a country,” Jonathan Goyer says, “when I had a conversation with a kid who was going through withdrawals.” Although he had enough money to get safer drugs, the kid was going to wait through the sweats and the diarrhea and the nausea until his dealer came in at 5 p.m. That would allow him to risk his life on fentanyl.

Those in heroin’s grip often say: “There are only two kinds of people—the ones I get money from and the ones I give money to.” A man who is dead to his wife and his children may be desperate to make a connection with his dealer. They don’t buy much besides heroin—perhaps a plastic cup of someone else’s drug-free urine on a day when they need to take a drug test for a hospital or employer. This will set them back twenty or thirty dollars. In addiction, as in more mainstream endeavors, the lords of hedonism are the slaves of money. Gilberto in Rhode Island claims to have put a million dollars into each of his needle-pocked arms, at the rate of three fifty-bag “bricks” of heroin a day.

Dealers are businessmen and behave like businessmen, albeit heavily armed ones. They may “throw something” to a particularly reliable customer—that is, give him enough heroin from time to time to allow him to deal a bit on his own account and stay solvent. An addict who discovers that the 10mg pills he is paying $18 each for in Maine are available for $10 in Boston, a three-hour drive away, may be tempted to sell them to support his own habit. The line between users and pushers blurs, rendering impractical the policy that most people prefer—be merciful to drug users, but come down hard on dealers.

Addicts wake up “sick,” which is the word they use for the tremulous, damp, and terrifying experience of withdrawal. They need to “make money,” which is their expression for doing something illegal. Some neighborhood bodegas—the addicts know which ones—will pay 50 cents on the dollar for anything stolen from CVS. That is why razor blades, printer cartridges, and other expensive portable items are now kept under lock and key where you shop. Addicts shoplift from Home Depot and drag things from the loading docks. They pull off scams. They will scavenge for thrown-out receipts in trash cans outside an appliance store, enter the store, find the receipted item, and try to return it for cash. On the edge of the White Mountains in Maine, word spread that the policy at Hannaford, the dominant supermarket chain, was not to dispute returns of under $25. For a while, there was a run on the big cans of extra virgin olive oil that sold for $24.99, which were brought to the cash registers every day by a succession of men and women who did not, at first sight, look like connoisseurs of Mediterranean cuisine. Women prostitute themselves on Internet sites. Others go into hospital emergency rooms, claiming a desperately painful toothache that can be fixed only with some opioid. (Because if pain is a “fifth vital sign,” it is the only one that requires a patient’s own testimony to measure.) This is generally repeated until the pain-sufferer grows familiar enough to the triage nurses to get “red-flagged.”

The population of addicts is like the population of deer. It is highest in rustic places with access to urban supplies. Missouri’s heroin problem is worst in the rural counties near St. Louis. New Hampshire’s is worst in the small cities and towns an hour or so away from the drug markets of Massachusetts: Lawrence, Lowell, and Boston. But the opioid epidemic of the past decade is unusually diverse. Anchor’s emergency room clients are 82 percent white, 9 percent Hispanic, and 6 percent black. The state of Rhode Island is 85 percent white, 9 percent Hispanic, and 5 percent black. “I try to target outreach,” Goyer says, “but the demographics are too random for that.”

Drug addiction used to be a ghetto thing. Now Oxycodone has joined shuttered factories and Donald Trump as a symbol of white working-class desperation and fecklessness. The reaction has been unsympathetic. Writes Nadja Popovich in The Guardian: “Some point to this change in racial and economic demographics as one reason many politicians have re-evaluated the tough ‘war on drugs’ rhetoric of the past 30 years.”

The implicit accusation is that only now that whites are involved have racist authorities been roused to act. This is false in two ways. First, authorities have not been roused to act. Second, when they do, they will have epidemiological, and not just tribal, grounds for doing so. A plague afflicting an entire country, across ethnic groups, is by definition more devastating than a plague afflicting only part of it. A heroin scourge in America’s housing projects coincided with a wave of heroin-addicted soldiers brought back from Vietnam, with a cost peaking between 1973 and 1975 at 1.5 overdose deaths per 100,000. The Nixon White House panicked. Curtis Mayfield wrote his soul ballad “Freddie’s Dead.” The crack epidemic of the mid- to late 1980s was worse, with a death rate reaching almost two per 100,000. George H. W. Bush declared war on drugs. The present opioid epidemic is killing 10.3 people per 100,000, and that is without the fentanyl-impacted statistics from 2016. In some states it is far worse: over thirty per 100,000 in New Hampshire and over forty in West Virginia.

In 2015, the Princeton economists Angus Deaton and Anne Case released a paper showing that the life expectancy of middle-aged white people was falling. Prominent among the causes cited were “the increased availability of opioid prescriptions for pain” and the falling price and rising potency of heroin. Census figures show that Case and Deaton had put the case mildly: Life expectancy was falling for all whites. Although they are the only racial group to have experienced a decline in longevity—other races enjoyed steep increases—there are still enough whites in the United States that this meant longevity fell for the country as a whole.

Bill Clinton alluded to the Case-Deaton study often during his wife’s presidential campaign. He would say that poor white people are “dying of a broken heart.” Heroin has become a symbol of both working-class depravity and ruling-class neglect—an explosive combination in today’s political climate.

Maine’s politicians have taken the opioid epidemic as seriously as any in the country. Various new laws have capped the maximum daily strength of prescribed opioids and limited prescriptions to seven days. The levels are so low that they have led some doctors to warn that patients will go onto the street to get their dosages topped off. “We were sad,” State Representative Phyllis Ginzler said in January, “to have to come between doctor and patient.” She felt the deadly stakes of Maine’s problem gave her little alternative.

Paul LePage, the state’s garrulous governor, has been even more direct. Speaking of drug dealers at a town hall in rural Bridgton in early 2016, he said: “These are guys with the name D-Money, Smoothie, Shifty, these types of guys. They come from Connecticut and New York, they come up here, they sell their heroin, they go back home. Incidentally, half the time they impregnate a young white girl before they leave.” This is what the politics of heroin threatens to become nationwide: To break the bureaucratic inertia, one side will go to any rhetorical length, even invoking race. To protect governing norms, the other side will invoke decency, even as the damage mounts. It is what the politics of everything is becoming nationwide. From town to town across the country, the correlation of drug overdoses and the Trump vote is high.

The drug problem is already political. It is being reframed by establishment voices as a problem of minority rights and stigmatization. A documentary called The Anonymous People casts the country’s 20 million addicts as a subculture or “community” who have been denied resources and self-respect. In it, Patrick Kennedy, who was Rhode Island’s congressman until 2011 and who was treated for OxyContin addiction in 2006, says: “If we can ever tap those 20 million people in long-term recovery, you’ve changed this overnight.” What’s needed is empowerment. Another interviewee says, “I refuse to be ashamed of what I am.”

This marks a big change in attitudes. Difficult though recovery from addiction has always been, it has always had this on its side: It is a rigorously truth-focused and euphemism-free endeavor, something increasingly rare in our era of weasel words. The face of addiction a generation ago was that of the working-class or upper-middle-class man, probably long and intimately known to his neighbors, who stood up at an AA meeting in a church basement and bluntly said, “Hi, I’m X, and I’m an alcoholic.

The culture of addiction treatment that prevails today is losing touch with such candor. It is marked by an extraordinary level of political correctness. Several of the addiction professionals interviewed for this article sent lists of the proper terminology to use when writing about opioid addiction, and instructions on how to write about it in a caring way. These people are mostly generous, hard-working, and devoted. But their codes are neither scientific nor explanatory; they are political.

The director of a Midwestern state’s mental health programs emailed a chart called “‘Watch What You Call Me’: The Changing Language of Addiction and Mental Illness,” compiled by the Boston University doctor Richard Saltz. It is a document so Orwellian that one’s first reaction is to suspect it is a parody, or some kind of “fake news” dreamed up on a cynical website. We are not supposed to say “drug abuse”; use “substance use disorder” instead. To say that an addict’s urine sample is “clean” is to use “words that wound”; better to say he had a “negative drug test.” “Binge drinking” is out—“heavy alcohol use” is what you should say. Bizarrely, “attempted suicide” is deemed unacceptable; we need to call it an “unsuccessful suicide.” These terms are periphrastic and antiscientific. Imprecision is their goal. Some of them (like the concept of a “successful suicide”) are downright insane. This habit of euphemism and propaganda is not merely widespread. It is official. In January 2017, less than two weeks before the end of the last presidential administration, drug office head Michael Botticelli issued a memo called “Changing the Language of Addiction,” a similarly fussy list of officially approved euphemisms.

Residents of the upper-middle-class town of Marblehead, Massachusetts, were shocked in January when a beautiful twenty-four-year-old woman who had excelled at the local high school gave an interview to the New York Times in which she described her heroin addiction. They were perhaps more shocked by her description of the things she had done to get drugs. A week later, the police chief announced that the town had had twenty-six overdoses and four deaths in the past year. One of these, the son of a fireman, died over Labor Day. At the burial, a friend of the dead man overdosed and was rushed to the hospital. One fireman there said to a mourner that this was not uncommon: Sometimes, at the scene of an overdose, they will find a healthy- and alert-looking companion and bring him along to the hospital too, assuming he might be standing up only because the drug hasn’t hit him yet. In communities like this, concerns about “hurtful” words and stigma can seem beside the point.

Former Bush administration drug czar John Walters and two other scholars wrote last fall, “There is another type of ‘stigma’ afflicting drug users—that their crisis is somehow undeserving of the full resources necessary for their rescue.” Walters is talking largely about law enforcement. As he said more recently: “If someone were getting food poisoning from cans of tuna, the whole way we’re doing this would be more aggressive.”

Which is not the direction we’re going. In state after state, voters have chosen to liberalize drug laws regarding marijuana. If you want an example of mass media–induced groupthink, Google the phrase “We cannot arrest our way out of the drug problem” and count the number of politicians who parrot it. It is true that we cannot arrest our way out of a drug problem. But we cannot medicate and counsel our way out of it, either, and that is what we have been trying to do for almost a decade.

Calling addiction a disease usefully describes certain measurable aspects of the problem—particularly tolerance and withdrawal. It fails to capture what is special and dangerous about the way drugs bind with people’s minds. Almost every known disease is something people wish to be rid of. Addiction is different. Addicts resist known cures—even to the point of death. If you do not reckon with why addicts go to such lengths to continue suffering, you are unlikely to figure out how to treat them. This turns out to be an intensely personal matter.

Medical treatment plays an obvious role in addressing the heroin epidemic, especially in the efforts to save those who have overdosed or helping addicts manage their addictions. But as an overall approach, it partakes of some of the same fallacies as its supposed opposite, “heartless” incarceration. Both leave out the addict and his drama. Medicalizing the heroin crisis may not stigmatize him, but it belittles him. Moral condemnation is an incomplete response to the addict. But it has its place, because it does the addict the compliment of assuming he has a conscience, a set of thought processes. Those thought processes are what led him into his artificial hell. They are his best shot at finding a way out.

In 1993, Francis F. Seeburger, a professor of philosophy at the University of Denver, wrote a profound book on the thought processes of addicts called Addiction and Responsibility. We tend to focus on the damage addiction does. A cliché among empathetic therapists, eager to describe addiction as a standard-issue disease, is that “no one ever decides to become an addict.” But that is not exactly true, Seeburger shows. “Something like an addiction to addiction plays a role in alladdiction,” he writes. “Addiction itself . . . is tempting; it has many attractive features.” In an empty world, people have a need to need. Addiction supplies it. “Addiction involves the addict. It does not present itself as some externally imposed condition. Instead, it comes toward the addict as the addict’s very self.” Addiction plays on our strengths, not just our failings. It simplifies things. It relieves us of certain responsibilities. It gives life a meaning. It is a “perversely clever copy of that transcendent peace of God.”

The founders of Alcoholics Anonymous thought there was something satanic about addiction. The mightiest sentence in the book of Alcoholics Anonymous is this: “Remember that we deal with alcohol—cunning, baffling, powerful!” The addict is, in his own, life-damaged way, rational. He’s toorational. He is a dedicated person—an oblate of sorts, as Seeburger puts it. He has commitments in another, nether world.

That makes addiction a special problem. The addict is unlikely ever to take seriously the counsel of someone who has not heard the call of that netherworld. Why should he? The counsel of such a person will be, measured against what the addict knows about pleasure and pain, uninformed. That is why Twelve Step programs and peer-to-peer counseling, of the sort offered by Goyer and his colleagues, have been an indispensable element in dragging people out of addiction. They have authority. They are, to use the street expression, legit.

The deeper problem, however, is at once metaphysical and practical, and we’re going to have a very hard time confronting it. We in the sober world have, for about half a century, been renouncing our allegiance to anything that forbids or commands. Perhaps this is why, as this drug epidemic has spread, our efforts have been so unavailing and we have struggled even to describe it. Addicts, in their own short-circuited, reductive, and destructive way, are armed with a sense of purpose. We aren’t. It is not a coincidence that the claims of political correctness have found their way into the culture of addiction treatment just now. This sometimes appears to be the only grounds for compulsion that the non-addicted part of our culture has left.

Study Analyzes Pediatric Opioid Exposures

177Using data from the National Poison Data System, a new study published in the journal Pediatrics examined the more than 188,000 reported exposures to prescription opioids among children and adolescents younger than 20 years old between 2000 and 2015. The study found that healthcare facility (HCF) admission occurred in 8.7 percent and 21.5 percent of exposures among children aged 0-5 years and teenagers, respectively, while serious outcomes were more frequent among teenagers. Highlights from the report included:

  • The annual number and rate of exposures increased early in the study period but declined after 2009, except for buprenorphine exposures, which increased during the last three years of the study;
  • Hydrocodone accounted for the largest proportion of exposures (28.7 percent), and 47.1 percent of children exposed to buprenorphine were admitted to an HCF;
  • Children aged 0-5 years accounted for almost 90 percent of buprenorphine exposures;
  • The odds of being admitted to an HCF were higher for teenagers than for children aged 0-5 years; and
  • The rate of prescription opioid-related suspected suicides among teenagers increased by 52.7 percent during the study period.

The study concluded that greater efforts are needed to prevent opioid exposure to children of all ages, while particular attention should be paid to buprenorphine exposures among young children, which frequently result in HCF admission and are not declining in frequency.

Despite progress, Lake County’s fight against opioid epidemic sees early setbacks in 2017

il_lcnsIt was only three days into the New Year when Lake County sheriff’s deputies responded to a report of an unconscious man at a Deep Lake Road home outside Lake Villa. The 27-year-old’s heroin overdose was reversed by deputies using the opiate antidote Naloxone.

Since then, the saves have just kept on coming for the sheriff’s office.

On Jan. 8, deputies responded to a car accident in Ingleside, near Rollins and Wilson roads, and found the driver of one of the vehicles unconscious. Deputies determined the 31-year-old was overdosing on opioids, but the first dose of Naloxone had no effect. A second deputy arrived and two more doses were administered before the driver regained consciousness. Four days later, a 30-year-old Ingleside woman found by a family member could not be revived. The following day, deputies were successful in reviving a 30-year-old man from unincorporated Libertyville who needed two doses.

Last year, the sheriff’s office was responsible for saving 14 lives using Naloxone, and if the start of 2017 is any indication, the opioid epidemic might be increasing. In 2016, deputies saved two people in January and didn’t have another save until March.

“This is a major communitywide problem. Overdose from opioids has become far too common and exactly why treatment is a critical component,” said Undersheriff Ray Rose, who is part of the Lake County Opioid Initiative. “We as a community have to ensure those suffering from opioid addiction receive proper treatment to end this epidemic.

Mary Gardner of Waukegan, seen here in June 2016, is one of the former opioid addicts who received extended treatment through the Lake County Health Department’s Medication Assisted Treatment program. (By Frank Abderholden / Lake County News-Sun)

“We need to give people a second chance to get where they need to be,” he said. “But that alone is not the solution. One guy we saved — it was the fourth time we saved him. That’s why treatment is the next step. That’s how we will be able to solve the epidemic.”

Sheriff Mark Curran said deputies have saved more than 25 lives since the Naloxone program began just over two years ago.

“While I am grateful for the lives saved, we are currently in an opioid epidemic and are losing far too many lives to opioids,” Curran said.

According to the latest statistics from the Lake County coroner’s office, opioid or heroin-related deaths went up from 39 in 2014 to 42 in 2015.

Lake County Coroner Dr. Howard Cooper said that for the first three quarters of 2016, there were 31 opioid- or heroin-related deaths, which was down from the same period in 2015.

“It’s an epidemic, and not just in Lake County but the nation as a whole,” Cooper said. “The biggest problem is (heroin) is very inexpensive and very easily obtained. So it’s a huge problem.”

Contraband recently seized by the Lake County Sheriff’s Office includes heroin and prescription drugs. (Lake County Sheriff’s Office)

Debbie Guggenheim, director of the Jordan Michael Filler Foundation of Highland Park — which is named for a 23-year-old man who died of an overdose in January 2014 — said the epidemic is getting worse. She said police have made 130 saves since the program started three years ago

In October, the foundation donated almost 1,500 doses of Naloxone nasal spray to the Lake County Opioid Initiative to supply police officers with the antidote for 2017. The foundation has also pushed for legislation to loosen privacy laws when parents are trying to find out medical conditions of their 18-year-olds, who as adults are protected under the law from having doctors disclose any medical information about them.

“We are still fighting an uphill battle for sure,” she said of opioid addiction in general. “It’s a major, major problem.”

A specific problem Guggenheim sees is the rise of fentanyl overdoses, which are usually fatal because the synthetic opioid is so much more powerful than heroin.

“It’s now in pill form, and it’s frightening,” she said. “It’s lethal to the touch. If you have an open sore or get enough on your skin, it can kill. It’s terrifying, and it’s being cut with heroin more and more.”

Guggenheim added that fentanyl is so deadly it takes four to six doses of the antidote to revive victims, and most officers aren’t carrying four doses. She pointed out that the window in which a person overdosing needs the antidote is smaller with fentanyl than with heroin, where the antidote is needed within 3 to 4 minutes.

According to Cooper, there were eight fentanyl deaths in the county during the first three quarters of 2016. In 2015, there were three people with the drug in their system when they overdosed. He said fentanyl is about 100 times more powerful than morphine.

“The more publicity about (fentanyl), the better,” Guggenheim said. “Some parents have never heard of it.”

In Lake County, advocates, law enforcement, prosecutors and health services have teamed up under the umbrella of the Lake County Opioid Initiative to try and save lives and get people into treatment. They use a wide array of strategies.

At the organization’s website,, a map is featured of 31 places in the county where someone can take old prescription drugs or unused medication for disposal. All are police stations, except for Walgreens stores in Deerfield and Waukegan. Sometimes a young person’s first encounter with an opioid drug comes from the medicine cabinet at home or a friend’s house, according to the website.

Lake County State’s Attorney Michael Nerheim has also approached the problem in a number of ways, from drug court — where more than 30 people opted for treatment to avoid going to jail in 2016, a slightly higher number than in 2015 — to the newest program called “A Way Out.”

“It’s a pre-arrest strategy,” Nerheim said. Rather than getting arrested and then offered treatment, an addict in this program can go to one of seven police stations 24 hours a day, seven days a week, and tell authorities he or she is seeking treatment for their addiction. Drugs and paraphernalia can be turned over without charges.

“We’re trying to help people who have decided on their own to get treatment,” he said. “Anyone that struggles with an addiction knows sometimes there is a window of opportunity. A person wakes up at 2 a.m. and decides they are tired, they are done, they need help. Now they have somewhere to go.

“We’ve had over 60 people take advantage of it, and you don’t have to be a resident of that town,” Nerheim added. “We had one guy cross a couple of county lines from the south to go to Mundelein after hearing about it on the news. (It’s) about people ready to help themselves.”

Departments participating in A Way Out include Grayslake, Gurnee, Libertyville, Mundelein, Lake Forest, Round Lake Beach and Round Lake Park. Nerheim said other departments can refer people to those departments.

When people do end up in jail with an addiction, Rose said officials have a program for them. Since August, five people joined a program where they are given Vivatrol, which can cut opioid cravings for up to 28 days with a single injection. According to Rose, Lake County is only the second county in the state to administer the drug, whose cost has dropped from $1,100 per treatment to just $3.

“It’s the best option in terms of treatment,” Rose said. “It cuts the craving and the need for opioids, and it does a good job of doing it. This really seems to be a success. The problem is once they are out, they need to seek treatment on their own.”

Lake County Opioid Initiative co-founder Chelsea Laliberte — who lost her brother, Alex “Lali” Laliberte, in December 2008 to an overdose involving heroin and other drugs — said A Way Out will be expanded this year to a few more departments because a little more funding is available.

“That program has helped 65 people since June,” said Laliberte, whose family started Live4Lali, a foundation fighting to save lives through the antidote.

Live4Lali also has a clinic in Arlington Heights, open three days a week, where parents can get educational materials, free training and the antidote if they suspect their child may be experimenting with heroin or opioids. They have trained 600 parents, and Lali’s Law in Illinois now allows someone to ask for the antidote at a pharmacy.

“It’s always about ‘just in case,'” Laliberte said. “There is a stigma that families don’t want to talk about it because they are so ashamed.”

She added that the problem of opioid addiction knows no geographical boundaries, with the 130 saves happening in towns from Antioch to Zion, Waukegan to Fox Lake, and more high-income communities like Highland Park, Deerfield, Libertyville and Buffalo Grove.

“This is an issue that affects all walks of life,” Laliberte said. “This is not going away. People need to reach out and ask for help. There are so many resources out there.”

Cooper said his office is starting a pilot program this spring to address the issue with high school students.

“I believe to stop it, we need to get into the schools,” he said. “I want kids to know that the first time you try (opioids), you can be hooked. And it’s a very difficult habit to break.”

Next school year, Cooper said he intends to go to all the high schools in the county and then maybe middle schools.

This year, the Lake County Health Department’s Behavioral Health and Primary Care program will use a $325,000 grant from the U.S. Health Resources and Services Administration, an agency with the U.S. Department of Health and Human Services, to double the number of people in its Medication Assisted Treatment program for opioid addiction.

“We’ve added 65 patients as part of our program, and our goal is to get to 100 new clients,” said Loretta Dorn, director of clinical operations for the program. “That will bring the total to 200 overall. It shows you what kind of need there is.”

According to Dorn, it takes about a week from the first call to get into the program, which is offers outpatient treatment only.

“We found people can be successful in outpatient treatment,” she said. “But there are a lot of people who need more additional treatment.”

Dominic Caputa, the Health Department’s associate director of clinical operations, said the other aim of the program is get people additional services.

“They can get access to therapy, primary care and a dentist,” he said, adding that charges are based on a sliding scale of affordability.

Nerheim said some progress is being made, because Lake County is doing better at addressing opioid addiction than other areas of the country.

“Nationally, the rates are still climbing, but here in Lake County they are leveling off and declining,” he said, adding that some of the decline can be attributed to all the overdose saves that didn’t become a death statistic.

Between 2000 and 2015, the national rate of deaths from drug overdoses has increased 137 percent, including a 200 percent increase in the rate of overdose deaths involving opioids, which are classified as opioid pain relievers and heroin, according to the Centers for Disease Control and Prevention.

More persons died from drug overdoses in the United States in 2014 than during any previous year on record. From 2000 to 2014, nearly half a million people in the United States died from drug overdoses. In 2014, there were approximately 1.5 times more drug overdose deaths in the United States than deaths from motor vehicle crashes, according to the CDC.

Laliberte said Lake County is fortunate, because many other areas in Illinois and other states do not have the cooperation between the community, advocates, law enforcement and the health department.

“It’s working. It’s not perfect, but we’re certainly making a lot of progress,” she said. “It’s a very complex problem and requires us to try new strategies. Really it’s a community problem and it will take a community response.”

No Needle Needed: America’s Heroin Epidemic

areas-in-the-us-with-the-highest-heroin-abuse-1For years, drug addiction advocacy groups have warned there was a growing epidemic in the U.S. that would only get worse if lawmakers failed to pay attention. Specifically, the concern for many was that heroin was becoming more and more appealing to teenagers — many of whom were overdosing and dying.

Nationwide, heroin deaths increased 45 percent between 1999 and 2010.

In 2002, 166,000 Americans reported using the drug, but in 2012, 335,000 Americans said they had used heroin in the past year. But according to Michael’s House, a rehab facility for recovering heroin addicts, the average age of heroin users in the U.S. is currently 21 years old.

Heroin use has become so problematic in some states such as Vermont that the state’s Gov. Peter Shumlin devoted much of his State of the State address to discuss the use of the drug in the state.

Unlike the heroin of yesteryear, which required a needle, users nowadays can buy a powder-filled capsule that can be broken open and snorted — for just $10.

Part of the attraction to heroin for many teens is the price and ease of ingesting the drug.

Unlike the heroin of yesteryear, which required the use of a needle, users nowadays can buy a button — a powder-filled capsule that can be broken open and snorted — for just $10. And the drug is widely available.

And instead of buying from a dealer in an alley, teens can purchase buttons from people on varsity sports teams, Ivy League campuses and in suburban neighborhoods.

Addiction fueled by pain pills

What’s even more terrifying for some such as Dan Duncan, associate executive director at St. Louis’s National Council on Alcoholism and Drug Abuse, is that most heroin users’ addiction starts with the use of pain pills.

According to Dr. Nora Volkow, director of the National Institute on Drug Abuse, there were 210 million prescriptions for opiate medications written in 2011 alone in a country with 312 million people. But since the pills are so expensive on the black market, many turn to a cheaper alternative like heroin, which is a painkiller.

Andrew Jones’ family knows this to be true all too well. Jones was in his sophomore year of college when he had his first experience with an opiate. Though Jones was always someone who discouraged drug use, including marijuana, Jones became addicted to prescription painkillers after he had to take them for a virus that damaged his pancreas, broke his hand and had his wisdom teeth removed.

“He would steal them, he would buy them, he would find them wherever he could,” said Jones’ friend Katie Gerstenkorn. “He stole painkillers from me, actually.”

Although experts say it takes months or longer to become truly habituated to heroin, Jones’ friends and family say that after he was given a capsule of heroin at a party, he became hooked.

“He couldn’t get away from the drug,” said his mom, Pam. “It’s a hunger, it’s a thirst. You throw all your morals out the window.”

Jones eventually began stealing money from his roommates so he could buy more heroin. He went to rehab, was released –then overdosed, and then went back to rehab.

His family and friends said they thought he was going to overcome his addiction, but soon Jones overdosed and died at the age of 23.

Jones’ story is tragic, and drug addiction experts say that his is a typical story. Duncan said that in 2008 the NCADA saw a spike in the number of people calling the organization’s help line, and Duncan says most of those calls were specifically about helping teens.

“It became clear that this was a problem in some of the best high schools in the area,” he said. “Public, private, most of them,” .

St. Louis County Police Chief Tim Fitch added that what he found most startling about the surge in deaths from heroin overdoses was the average age of the users.

“Historically the age for most heroin deaths has been in the 40-to-45 range,” Fitch said. “But now the average age is between 18 and 25.”

And as “Emily” told TeenVogue, she started using heroin at the age of 14 after joining the varsity cheerleading squad at her school. By the age of 15, Emily says she was a regular user, but she was able to hide her addiction by getting good grades and staying out of trouble.

“It was like I was leading a double life,” she said. “I thought, maybe this is my little secret, and it’s not as bad as everyone says it is.”

Emily says at first she only used the drug during the weekend, which she got from a friend of a friend’s 30-year-old brother. She said he gave her the drug for free and then began to pressure her to have sex with him, which she eventually agreed to.

“I slept with him because I felt like he was giving something to me, so I had to give something to him,” she said.

Soon Emily was skipping school, decided to not try out for the cheerleading squad, and began to use heroin on a daily basis. Emily said it wasn’t until a friend of hers expressed an interest in trying the drug on her 16th birthday that she realized heroin was a drug many other teens were using as well.

During the next two years Emily went to rehab six times, overdosed twice, and attended 12-step meetings, but she continued to use the drug. But then she says something in her brain clicked.

“I was willing to go to any length to get high, and then it became clear that I needed to go to any length to get sober,” she said. “I had to change every single thing in my life, which was terrifying. But when the pain of staying the same was greater than the pain of change, that’s when I knew I really had to do something.”

“We can’t arrest our way out of this”

In an interview with the PBS NewsHour earlier this month, Shumlin said that since 2000, there has been a 770-percent increase in the number of people seeking treatment for opiate addictions.

“What started as an OxyContin and prescription drug addiction problem in this state has now grown into a full-blown heroin crisis,” he said. “Last year, we had nearly double the number of deaths in Vermont from heroin overdose as the previous year.”

While Shumlin says that the heroin epidemic is by no means more serious than the problem that is occurring in other states, he said the difference is that “I’m willing to confront it and, as governor, take it on head on. …

“We have lost the war on drugs,” he added. “The notion that we can arrest our way out of this problem is yesterday’s theory … As far as I’m concerned, this is one of the real battles that we’re facing that we have got to win. And we have got to do that by changing the discussion and changing the policy, so that we say that what heroin addicts and folks that are addicted to opiates are facing is a public health issue, not a crime issue. And we have got to be willing to fight it from that vantage point.”

Dr. Gabor Maté concurred. He told Vice that after helping many heroin addicts find sobriety, he agrees that our current prevention and recovery methods are failing, and says we need to reconsider what causes an addiction and change our approach in how we help addicts.

He said part of ending this epidemic is figuring out why kids are taking heroin, which he says is the strongest pain reliever known to medical professionals, and relieves physical and emotional pain. Maté says the real question is not why is there a heroin epidemic, but why is there so much pain among young people today?

Maté explained that some children are traumatized and abused during their childhood, which is why they turn to drugs like heroin. The other reason is that there are people who are not getting their emotional needs met and are indirectly abused.

“Their parents are too busy, too stressed, too distracted, too depressed, too overwhelmed themselves to give them what they need,” he said. “So children grow up with a sense of emotional lack and emptiness, fear, and distress. Heroin partially soothes that pain and that distress.”

Maté went on to explain that people are continuing to use drugs such as alcohol and heroin despite all of the warnings, and adds that part of the reason so many young people die is that rehab and addiction programs appear to be ineffective and unsuccessful for the most part.

He pointed to actor Cory Monteith as an example, and said the actor, who died of a heroin overdose last year, repeatedly went to rehab since the age of 19. He died when he was 31.

“Addiction is not the problem,” Maté said. “Addiction is the addict’s attempt to solve a problem.”

World Premier of the “A Way Out” introduction video!

Push to combat drug trade may mean starting with China, responsible for the majority of fentanyl

AP News– If President-elect Donald Trump wants to fulfill his campaign promise of stemming the flow of drugs coming across the United States’ border with Mexico, he may want to start by looking at China.

Manufacturers and organized crime groups in the world’s most populous country are responsible for the majority of fentanyl — the synthetic opioid that is 50 times more potent than heroin — that ends up in the U.S. and the majority of precursor chemicals used by Mexican drug cartels to make methamphetamine, according to numerous published U.S. government reports.

“The Mexican cartels are buying large quantities of fentanyl from China,” Barbara Carreno, a spokesperson with the U.S. Drug Enforcement Administration (DEA), told “It’s much easier to produce than waiting around to grow poppies for heroin and it’s incredibly profitable.

China is responsible for the majority of fentanyl — the synthetic opioid that is 50 times more potent than heroin.

The DEA estimates that a kilogram of fentanyl, which sells for between $2,500 and $5,000 in China, can be sold to wholesale drug dealers in the U.S. for as much as $1.5 million and that the demand for the drug due to the prescription opioid crisis in places like New England and the Midwest have kept the prices high.

What is fentanyl

  • Fentanyl is a synthetic opioid, 50 times more potent than heroin, that’s responsible for a recent surge in overdose deaths in some parts of the country. It also has legitimate medical uses.
  • Doctors prescribe fentanyl for cancer patients with tolerance to other narcotics, because of the risk of abuse, overdose and addiction, the Food and Drug Administration imposes tight restrictions on fentanyl; it is classified as a Schedule II controlled substance.
  • The DEA issued a nationwide alert about fentanyl overdose in March 2015. More than 700 fentanyl-related overdose deaths were reported to the DEA in late 2013 and 2014. Since many coroners and state crime labs don’t routinely test for fentanyl, the actual number of overdoses is probably much higher.

Trump, along with numerous other presidential hopefuls, promised while on the stump in states hard-hit by drug addiction to quickly tackle the widespread use of drugs like fentanyl and heroin. While heroin addiction has been a concern for decades, in recent years the number of users of heroin and fentanyl — and its more potent derivatives like carfentanil — has skyrocketed as the government clamps down on the abuse of prescription opioids like OxyContin and Percocet.

“We’re going to build that wall and we’re going to stop that heroin from pouring in and we’re going to stop the poison of the youth,” Trump said during a September campaign stop in New Hampshire.

The problem with cracking down on fentanyl and its derivatives is that while these substances may be banned in the U.S., they may not be illegal in their country of origin. China, for example, only last year added 116 synthetic drugs to its controlled substances list, but failed to include carfentanil – a drug that is 10,000 times more potent than morphine and has been researched as a chemical weapon by the U.S., U.K., Russia, Israel, China, the Czech Republic and India.

“It can kill you if just a few grains gets absorbed through the skin,” Carreno said.

While Mexican cartels obtain these substances in large quantities through the murky backwaters of the Chinese black market, anybody with a credit card and Internet access can call one of the numerous companies in China’s freewheeling pharmaceutical industry that manufactures fentanyl and its more potent cousins.

Earlier this year, The Associated Press found at least 12 Chinese businesses that said they would export carfentanil to the United States, Canada, the United Kingdom, France, Germany, Belgium and Australia for as little as $2,750 a kilogram.

Besides synthetic opioids, Chinese companies are also producing massive amounts of the precursor chemicals used to make methamphetamine.

As the methamphetamine industry evolved over the last decade or so from small, homegrown operations in the U.S. to the super-labs run by Mexican cartels, cooks and producers of the drug have begun to rely more and more on China for their ingredients. Mexico now supplies 90 percent of the methamphetamine found in the U.S., and 80 percent of precursor chemicals used in Mexican meth come from China, according to a study by the U.S.-China Economic and Security Review Commission.

“China is the major source for precursor chemicals going to Mexico,” David Shirk, a global fellow at the Washington, D.C.-based Woodrow Wilson International Center for Scholars, told “The problem is finding who the connection is between organized crime groups in China and organized crime groups in Mexico.”

Shirk added that law enforcement and drug war experts generally have a good picture of the major players in Mexican organized crime, but the Chinese underworld is less well mapped and it is more difficult to pin down the major players in the drug trade there.

Despite U.S. efforts to crackdown on both the fentanyl and methamphetamine trades, U.S. government officials acknowledge that much of the onus lies with the Chinese. Chinese state officials take allegations of drug-related corruption seriously, launching investigations when deemed appropriate, but a U.S. State Department report found that drug-related corruption among local and lower-level government officials continues to be a concern.

When he takes office in January, Trump has a few things working in his favor in respect to combatting the drug trade.

One is the continued fracturing of some of Mexico’s largest and most powerful drug cartels. The Sinaloa Cartel, for example, was seen for years as an impenetrable drug organization until cracks began to appear in its armor following the re-arrest earlier this year of its leader, Joaquín “El Chapo” Guzmán, and the power struggle that ensued.

“When the violence goes up, business always goes down,” Shirk said.

Another factor that will help Trump’s war on drugs is U.S. anti-drug officials claim that their work in collusion with their Chinese counterparts is already helping greatly. Six months after China added a slew of synthetic drugs to its controlled substances list, monthly seizures in the U.S. of acetylfentanyl — a weak variant of fentanyl — were down 60 percent, the DEA reported.

 “We’re continuing to work with the Chinese to see if they might control more of these substances,” Carreno said. “When they put controls on these substances it makes a huge difference.”