Ms. Celina B. Realuyo is a Professor of Practice at the William J. Perry Center for Hemispheric Defense Studies at National Defense University.
Heroin use has spread into suburban and rural communities and is growing among most socioeconomic classes, age groups, and races. Potent synthetic opioids like fentanyl have become mixed into black-market supplies of heroin, cocaine, and methamphetamine and are fueling a high-mortality rate, and compounding the crisis.1 Unfortunately, U.S. military veterans, many of whom suffer from chronic pain as a result of their service, are twice as likely as the average American to die from a drug overdose involving an opioid.2
This crisis is adversely impacting public health, social welfare, the economy, and the national security of the United States. Canada and Mexico are similarly experiencing increased opioid trafficking, use, and addiction. This article will describe the evolution of the opioid trade and epidemic, examine current policies that address supply and demand reduction in the United States and abroad, and advocate the urgent need for more prevention, treatment, and interdiction efforts through interagency, inter-sectorial, and international collaboration.
Opioid Epidemics are not New
Ancient Egyptians traded opium, then known as the “joy plant,” an effective painkiller, throughout the Mediterranean. It is believed that Arab merchants brought it to China in the 7th century. English merchants, led by the British East India Company, from 1772–1850 established extensive opium supply chains to dominate sales in Europe and East Asia, creating the world’s first drug cartel.3 When the number of Chinese addicts had grown to an estimated 4–12 million by 1838, the Chinese emperor banned opium. This led to the First Opium War (1839–42) between the United Kingdom and Qing dynasty. The United Kingdom won and forced the Qing Dynasty to allow British merchants to sell Indian-grown opium in China. The opium trade was lucrative, and smoking opium had become quite popular during the 19th century in both Asia and Europe.
In 1868, the United Kingdom enacted the Pharmacy Act to help curb addiction and death rates by allowing only pharmacists to sell drugs. The Act purportedly reduced the death rate caused by opium from 6.4 per million population in 1868 to 4.5 in 1869, but after a decade it had risen to more than 5 per million, and by the end of the century it was back at the 1868 level.4
In the United States, opium use spread after the Civil War with veterans addicted to morphine as pain relief for their wounds, and Americans consuming opium recreationally in opium dens and medicinally to alleviate coughing and even diarrhea in children. In 1895, the German drug company Bayer introduced a new wonder drug, more powerful than Aspirin, which worked phenomenally well as a cough suppressant, marketed in the United States under the brand name Heroin. Along with cocaine, it was recommended as a safe alternative to morphine for addicts trying to shake their dependency, and flooded the market in many forms.
By the late 19th century opioid addiction was a nationwide crisis, afflicting urban and rural areas and across the country’s social classes. The passage of the Pure Food and Drug Act of 1906 forced manufacturers to disclose the contents of their products, so consumers wary of the drug would know if it was in their children’s cough syrup. In 1909, Congress passed the Opium Exclusion Act, banning its import for the purpose of smoking.
In 1911, U.S. President Theodore Roosevelt appointed Dr. Hamilton Wright as the nation’s first Opium Commissioner. Dr. Wright had led an American delegation to the First International Opium Commission in Shanghai in 1909 and then led another to The Hague in 1912 that produced the first global attempt to regulate narcotics. Wright continued to press for U.S. legislation, despite the objections of drug manufacturers, which resulted in the Harrison Narcotics Tax Act of 1914 that taxed and tightly regulated the sale and distribution of opium and cocaine-based products.
At the peak of the 19th century addiction crisis in 1895, an estimated 300,000 Americans were hooked.5 Today the United States has four times as many people but perhaps 10 times as many addicts and the crisis is far more lethal.
Increased Usage and Increased Potency: Dangerous Crossroads
In 2017, drug overdoses killed an estimated 72,000 Americans—a record number that reflects a rise of about 10 percent over the previous year—according to the Centers for Disease Control and Prevention (CDC). This is a death rate higher than the peak yearly death totals from H.I.V., car crashes, or gun deaths.6 Analysts attribute the recent increase to two major causes: a growing number of Americans are using opioids, and drugs are becoming deadlier.
In the late 1990s, healthcare providers began to overprescribe opioid pain relievers after assurances from the pharmaceutical industry—“It’s not hypnotic,” and “there’s no danger of acquiring a habit,”—that patients would not become addicted.7 Opioid pain relievers generally are safe when taken for a short time and as prescribed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused (taken in a different way or in a larger quantity than prescribed, or taken without a doctor’s prescription).8 Regular use—even as prescribed by a doctor—can lead to dependence and, when misused, opioid pain relievers can lead to addiction, overdose, and potentially death. To satisfy intense cravings, users began purchasing heroin on the black market.
Since 2010, heroin availability in the United States has increased commensurately with the shift by Mexican transnational criminal organizations (TCOs) to heroin and fentanyl trafficking, and reduced poppy eradication efforts in Mexico. Heroin is small in volume and extremely lucrative; much more profitable than marijuana and cocaine. Traffickers can increase their profits and heighten the potency (and the “high”) from low-quality heroin by “cutting” it—or mixing it—with fentanyl.9 Due to its potency—30 to 50 times that of heroin—only very small amounts of fentanyl are added, but even a small amount can be lethal.
A National Emergency
In October 2017, President Donald Trump declared the opioid crisis a national Public Health Emergency under federal law and directed all executive agencies to use every appropriate emergency authority to fight the crisis, to include interdiction, treatment, and prevention efforts. In early 2018, President Trump authorized $6 billion for opioid crisis programs in the federal budget, with $3 billion allocated for 2018 and $3 billion allocated for 2019. This crisis does not discriminate based on gender, race, age, economic status, or affect only rural or urban populations. All sectors of society—public, private, and civic—are affected and must take a more active role in countering it through education, prevention, treatment, or interdiction efforts.
That Demands a Whole-of-Community Response
The White House Office of National Drug Control Policy (ONDCP) aims to reduce drug use and its consequences by leading and coordinating the development, implementation, and assessment of U.S. drug policy.16 Working with the Departments of Health and Human Services (HHS) and Justice (DOJ), and other agencies, ONDCP is addressing opioid consumption by promoting community-based drug prevention efforts, detecting early signs of opioid addiction, monitoring prescription drug programs, and increasing access to the opioid-overdose-reversing drug naxalone.17
In June the White House, ONDCP, and other partners unveiled a new, multimillion-dollar public awareness campaign aimed at curbing opioid addiction among young people. The first four 30-second public service announcements illustrate the extreme measures taken by young adults to obtain oxycodone (OxyContin®) and hydrocodone (Vicodin®)—from smashing their hands or arms, to wrecking their cars or even breaking their backs. In speaking about the initiative, White House counselor Kellyanne Conway told reporters:
We hope these ads will spark conversation to educate teens and young adults to talk to their doctors about alternatives to opioids; that pain management may not always mean extended pain medication use; safe disposal practices for leftover, unused prescription; and also, to arm them with specific yet very simple knowledge about opioids.18
Other initiatives aimed at curbing drug overdoses have been rolled out at the national level, including expanded access to naxalone, and new opioid prescription guidelines limiting the availability of prescription painkillers. In October, Congress almost unanimously passed and the President signed the Support for Patients and Communities Act that is considered a big breakthrough that will expand access to addiction treatment, enhance law enforcement efforts against the flow of illicit drugs, and combat the over-prescription of opioids.19
And Requires International Collaboration
ONDCP is also coordinating with the DOJ, Department of Homeland Security (DHS), Department of State (DOS), and international partners to help disrupt the trafficking of heroin and fentanyl, fentanyl analogues, and precursor chemicals onto U.S. soil. Drug trafficking continues to be the most lucrative illicit activity in the world and a destabilizing force that finances and empowers terrorists and criminal groups. The United States is focusing efforts to reduce drug supplies, like heroin and fentanyl, at their source and dismantle the TCOs that profit from them, particularly in the Western Hemisphere.
The United States is also complementing partner nation efforts to reduce crime and corruption in key drug source and transit countries, and their efforts to professionalize police and other security forces through various foreign assistance programs. These programs also seek to strengthen the rule of law, promote judicial reform, improve information sharing with our law enforcement partners, target criminals and corrupt leaders and disrupt illicit trafficking. The United States and Mexico are working hand-in-hand to address the opioid crisis by stemming the production and flow of heroin and fentanyl into the U.S. market. Meanwhile, the United States is cooperating with Mexico, China, and Canada to address the movement of precursor chemicals and synthetic opioids like fentanyl.
The Mexican TCOs have capitalized on Mexico’s proximity to the United States and Americans’ voracious appetite for illegal drugs, traditionally for marijuana and cocaine, and more recently for heroin and opioids. They have dominated the drug trade, and confronted the Mexican municipal, state, and federal governments for decades, and are engaged in a new opium war.
Mexico experienced a record number of homicides in 2017. The Mexican National Institute of Statistics and Geography reported that the country had 31,174 homicides in 2017, an increase of 27 percent compared with 2016, which saw 24,559 homicides. These newly released numbers also show an increase in Mexico’s homicide rate to 25 homicides per 100,000 inhabitants nationwide, up from 20 per 100,000 in 2016. Traffickers use violence to settle disputes and control routes and territory; threats of violence maintain employee discipline and a semblance of order with suppliers, creditors, and buyers. The violence in Mexico has escalated astronomically and is now directed toward the government, political candidates, and the news media and not just rival cartels.20 Public authorities there estimate that 40 percent of the country is subject to chronic insecurity, with homicidal violence, disappearances, and population displacement at all-time highs.21
After a decade of Mexican military deployment on law enforcement missions and continued violence and allegations of human rights abuses, there is a vibrant public debate over the appropriate role of the military and police in the continued fight against TCOs.22 The United States and Mexico have one of the most extensive bilateral military and law enforcement relationships in the world. Through the Merida Initiative initiated in 2008, the United States has helped build the capacity of Mexican authorities to more effectively eradicate opium poppy, disrupt and prosecute drug production and trafficking, and enhance border security.
The Mexican government eradicates both opium poppy (from which heroin is derived) and cannabis, and it increased its eradication efforts of both plant-based drugs in 2016. Despite these efforts poppy cultivation in Mexico increased to 32,000 hectares (ha) in 2016, from 28,000 ha in 2015, according to the State Department Bureau of International Narcotics and Law Enforcement Affairs.23 The U.S. Government estimated that Mexico’s potential production of heroin in 2016 totaled 81 metric tons, three times its estimated production in 2013. In 2016, Mexican forces seized roughly 13 metric tons of cocaine, 26 metric tons of methamphetamine, and about 235 kilograms of opium gum, while shutting down 136 clandestine drug laboratories.
In 2018, the Trump Administration intensified its efforts to help Mexico get a more detailed picture of its poppy problem and has begun to supply Mexican authorities with drones and geolocation technology. The Administration is also funding studies to pinpoint how much poppy is being planted and how much heroin is produced from it.24
To further broaden cooperation, the United States and Mexico held the first Cabinet-level Strategic Dialogue on Disrupting TCOs in May 2017, to define a new approach to addressing the business model of TCOs, with emphasis on drug production, drug distribution, cross-border movement of cash and weapons, drug demand markets, and illicit revenue. That month, the United States and Mexico also held the first-ever trilateral National Fentanyl Conference for forensic chemists from Mexico, the United States, and Canada to share best practices on the detection, analysis, and handling of fentanyl. The United States also engaged with Mexico and Canada at the 2017 North American Drug Dialogue to produce the first Trilateral Assessment on Opioid Trafficking. These ongoing dialogues are advancing efforts to disrupt drug trafficking in North America and to end impunity for the TCOs profiting from it.
It is unclear if and how the bilateral cooperation on poppy eradication, interdiction operations, and the fight against the cartels will continue between the United States and Mexico under newly elected Mexican President Andrés Manuel López Obrador (AMLO). He assumed office in December, having won the presidential election in July as a leftist populist with 53 percent of the vote, pledging to fight corruption and end the violence plaguing Mexico. On the campaign trail, AMLO repeated catchy slogans and rhymes to show his opposition to the militarized drug war. These included phrases like “Abrazos no balazos” (hugs, not gunshots), “Becarios sí, sicarios no,” (scholars yes, killers no), and “No puedes apagar el fuego con el fuego” (you cannot fight fire with fire).25
AMLO is expected to focus more on domestic matters like socio-economic development and anti-corruption rather than on counternarcotics efforts. There is concern that he will adopt the anti-U.S. stance that he advocated during his campaign and decrease bilateral cooperation on security matters.26 AMLO’s new National Plan for Peace and Security (2018–24) diverges from previous Mexican government policies and from U.S. law enforcement and counternarcotics interests. Specifically, the Plan aims to reform the Mexican security services by creating a Mexican National Guard, demilitarizing the conflict with the cartels, consider granting amnesty to drug traffickers, and legalizing marijuana and opium poppy cultivation.27
China is one of the world’s top producers and exporters of precursor chemicals and synthetic drugs like fentanyl. The majority of precursor chemical production and export from China is intended for legitimate use; however, precursors and synthetics are being diverted by TCOs and are also manufactured in large, sophisticated, illegal factories within China. Chinese criminal organizations traffic illicit drugs domestically and to international markets, and Chinese authorities have noted the presence of international drug trafficking organizations originating from Africa and Mexico operating within the country. China’s role as a major international financial center has also fueled an increase in illicit drug and precursor chemical-related money laundering activities.
The United States is cooperating with China to reduce the production and trafficking of illicit fentanyl and fentanyl analogues originating from China through joint law enforcement operations and information-sharing. In 2017, the United States and China regularly shared law enforcement information on new and emerging fentanyl analogues and illegal manufacturing and trafficking activity. For example, DHS and DOJ officials in Hong Kong worked with local customs and law enforcement authorities in 2017 to seize an estimated 50 packages containing fentanyl that were bound for the United States and Canada.28 The Bilateral Drug Intelligence Working Group and the Counter Narcotics Working Group, which reports to the U.S.–China Joint Liaison Group on Law Enforcement, also meet annually to exchange views and information on trends in drug abuse and trafficking, discuss pertinent laws, regulations, policies and procedures in the respective countries, address challenges in precursor chemical control, and find mechanisms to cooperate on investigations and cases of mutual interest.
The challenges posed by trafficking synthetics via the internet and small parcel trafficking patterns are formidable and will test the cooperative spirit and ingenuity of the law enforcement authorities in the United States and China.29 U.S. law enforcement continues to make inroads in building working relationships with provincial public security bureaus, with oversight by central authorities.30 In early December, on the margins of the G20 Summit in Buenos Aires, President Trump met with Chinese President Xi Jinping, who agreed to designate fentanyl as a controlled substance, meaning that those who sell fentanyl to the United States will be subject to China’s maximum penalty under the law—a promising development in efforts to reduce the supply and production of opioids.
Canada is the second largest per capita consumer of prescription opioids in the world after the United States, according to the International Narcotics Control Board. Canadian authorities reported that 65 percent of all analyzed heroin seizure samples tested during the first six months of 2017 contained fentanyl or its analogues.31 That year, prosecutors in Canada brought manslaughter charges against drug traffickers accused of selling fentanyl to hundreds of drug users who died as a result of fentanyl overdoses.
Canada is also a supplier of fentanyl, MDMA (ecstasy), and marijuana to the United States, so U.S. agencies cooperate extensively with Canada to enhance regulatory frameworks to prevent access to precursor chemicals and lab equipment for criminal use and stem the flow of illegal drugs across our shared border. Integrated teams of Canadian and U.S. law enforcement authorities operate in several locations along the northern border and the two countries also share information and conduct coordinated operations targeting the trafficking of synthetic drugs, particularly fentanyl and fentanyl precursors.32
Sadly, the current opioid crisis is reminiscent of past periods of addiction and overdose deaths in the United States. The crisis today, however, is on a much larger scale owing to how the American appetite for opioids has changed the nature of the drug trade in North America, from the consumption of marijuana and cocaine to that of heroin and fentanyl, and that Mexican TCOs have been quick to capitalize on this demand signal at the expense of record levels of drug-related violence and homicides in Mexico. The opioid epidemic is now a health, security, social, economic welfare, and national security crisis, with some 300 Americans dying from heroin overdoses per week—a rate that contributed to the second straight annual decline in U.S. life expectancy.
The United States Government is doubling down on its prevention, treatment, and supply interdiction measures at the national, state, and local levels to tackle the opioid epidemic. The public, private, and civic sectors must take a more active role in raising awareness of drug abuse and addiction to reduce the demand for opioids, particularly since this opioid epidemic does not discriminate against gender, race, age, economic status, or location. As a transnational crisis, international cooperation to address the supply of illicit opioids is also essential. This whole-of-society approach is required to triumph in the new opium war and overcome this latest opioid epidemic in North America. PRISM
1 Office of National Drug Control Policy, “Prescription Opioid Misuse, Heroin, and Fentanyl,” available at <https://www.whitehouse.gov/ondcp/key-issues/prescription-opioid-misuse/>.
2 Robert Wilkie, “Fighting Pain and Addiction for Veterans,” White House Media Release, October 26, 2018, available at <https://www.whitehouse.gov/articles/fighting-pain-addiction-veterans/>. For additional background see: Claire Felter, “The U.S. Opioid Epidemic Backgrounder,” Council on Foreign Relations, December 26, 2017, available at <https://www.cfr.org/backgrounder/us-opioid-epidemic>.
3 Eric Gutierrez, “Lessons from the Past Could Help Tackle Today’s Narcotics Trade,” New Internationalist, November 11, 2015, available at <https://newint.org/blog/2015/11/11/drugs-cartels>.
4 Virginia Berridge and Griffith Edwards, Opium and the People, Opiate Use in Nineteenth-Century England, (New York, Saint Martin’s Press: 1982), available at <https://web.archive.org/web/20131225190914/http://www.druglibrary.eu/library/books/opiumpeople/pharmact.html>.
5 “Inside the Story of America’s Opioid Addiction,” Smithsonian.com, available at <https://www.smithsonianmag.com/history/inside-story-americas-19th-century-opiate-addiction-180967673/>.
6 Margot Sanger-Katz, “Bleak New Estimates in Drug Epidemic: A Record 72,000 Overdose Deaths in 2017,” The New York Times, August 15, 2018, available at <https://www.nytimes.com/2018/08/15/upshot/opioids-overdose-deaths-rising-fentanyl.html>.
7 Miroff, op.cit. Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), Codeine, Morphine, and many others.
8 Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription, such as oxycodone (OxyContin®), hydrocodone (Vicodin®), Codeine, Morphine, and many others.
9 Leslie Cooley Dismukes, “How Did We Get Here? Heroin and Fentanyl Trafficking Trends, A Law Enforcement Perspective,” North Carolina Medical Journal, 79 no. 3 (May¬June 2018), 181¬84, available at <http://www.ncmedicaljournal.com/content/79/3/181.full>. This tragedy has been well depicted in Sam Quinones’ powerful book, Dreamland: The True Tale of America’s Opiate Epidemic, (Bloomsbury Press, 2015).
10 U.S. Department of Justice, “National Drug Threat Assessment, 2017” Drug Enforcement Administration, available at <DEA 2017 National Drug Threat Assessment, https://www.dea.gov/sites/default/files/docs/DIR-040-17_2017-NDTA.pdf>.
11 Joshua Partlow, “U.S. Has been Quietly Helping Mexico with New, High-tech Ways to Fight Opium,” The Washington Post, April 15, 2018, available at <https://www.washingtonpost.com/world/the_americas/us-has-been-quietly-helping-mexico-with-new-high-tech-ways-to-fight-opium/2018/04/15/dc18eda0-26d5-11e8-a227-fd2b009466bc_story.html?noredirect=on&utm_term=.89e2fa6be902>.
12 U.S. Department of Justice “National Drug Threat Assessment.” The DEA does not just interdict illegal narcotics and reduce drug flows but is also actively engaged in education and prevention programs. DEA’s 360 Strategy to combat heroin/opioid use issued on November 10, 2015 has three main goals: stopping the deadly cycle of heroin and opioid pill abuse by eliminating drug trafficking organizations and gangs fueling violence on the streets and cycles of addiction in our communities; partnering with the medical community and public to raise awareness of the dangers of prescription opioid misuse and conducting the National Prescription Drug Take Back Day for Americans to safely dispose of any unwanted, unused or expired prescription medications and strengthening community organizations best positioned to provide long-term help and support for building drug-free communities.
13 U.S. Department of State “2018 International Narcotics Control Strategy Report,” Bureau for International Narcotics and Law Enforcement Affairs, available at <https://www.state.gov/documents/organization/278759.pdf>.
15 Madeline Mitchell, “This Drug-busting Agency has More Power than the DEA, but We Can't Tell How They Use It,” Cincinnati Enquirer, August 18, 2018, available at <https://www.cincinnati.com/story/news/crime/oh-crime/2018/08/13/drugs-mail-how-postal-service-fighting-drugs-cincinnati-mystery/673509002/> The top priority of the U.S. Postal Inspection Service is protecting the U.S. Mail and its consumers. According to the U.S. Postal Service, inspectors seized more than 40,000 pounds of illegal drugs along with $22,487,980 from packages, resulting in 1,954 arrests in 2017.
16 White House Office of National Drug Control Policy, “Mission Statement,” available at<https://www.whitehouse.gov/ondcp/>.
18 The 30-second ads, reminiscent of Nancy Reagan’s “Just Say No” Campaign, were produced in partnership with the Truth Initiative, the Ad Council, and the White House Office of National Drug Control Policy will air on television and digital platforms. The ad funding mostly came private partners, including Facebook, Google, YouTube, NBC, Amazon, VICE, and Turner.
19 German Lopez, “Trump Just Signed a Bipartisan Bill to Confront the Opioid Epidemic,” Vox.com, October 24, 2018, available at <https://www.vox.com/policy-and-politics/2018/9/28/17913938/trump-opioid-epidemic-congress-support-act-bill-law>.
20 U.S. Library of Congress, Congressional Research Service, Mexico: Organized Crime and Drug Trafficking Organizations, by June S. Beittel, R41756 (July 3, 2018), available at <https://fas.org/sgp/crs/row/R41576.pdf>.
21 Robert Muggah and John P. Sullivan, “The Coming Crime Wars,” Foreign Policy, September 21, 2018, available at <https://foreignpolicy.com/2018/09/21/the-coming-crime-wars/>.
22 Christopher Woody, “After a Decade Fighting the Cartels, Mexico May be Looking for a Way to Get its Military Off the Front Line,” Business Insider, February 13, 2017, available at <http://www.businessinsider.com/mexican-military-role-in-fighting-drug-war-and-cartels-2017-2>.
23 U.S. Department of State “2018 International Narcotics Control Strategy Report,” 221.
24 Joshua Partlow, “U.S. has Been Quietly Helping Mexico with New, High-tech Ways to Fight Opium,” The Washington Post, April 15, 2018, available at <https://www.washingtonpost.com/world/the_americas/us-has-been-quietly-helping-mexico-with-new-high-tech-ways-to-fight-opium/2018/04/15/dc18eda0-26d5-11e8-a227-fd2b009466bc_story.html?noredirect=on&utm_term=.89e2fa6be902>.
25 James Fredrick, “Mexico’s New President has a Radical Plan to End the Drug War,” Vox, August 15, 2018, available at <https://www.vox.com/2018/8/15/17690420/mexico-president-amlo-drug-war-cartels-violence-legalization>.
26 U.S. Library of Congress, 7.
27 “Los 8 Ejes del Plan Nacional de Paz y Seguridad de AMLO” [The 8 Axes of AMLO’s National Peace and Security Plan],” El Financiero, November 14, 2018, available at <http://www.elfinanciero.com.mx/nacional/los-8-ejes-del-plan-nacional-de-seguridad-y-paz-de-amlo>.
28 DHS involvement included Immigration and Customs Enforcement (ICE) and Homeland Security Investigations (HSI), whereas DOJ involvement included the Drug Enforcement Administration (DEA). U.S. Government Accountability Office (GAO), Illicit Opiods: While Greater Attention Given to Combating Synthetic Opioids, Agencies Need to Better Assess their Efforts, GAO-1825, Washington D.C., March 2018, available at <https://www.gao.gov/assets/700/690972.pdf>.
31 U.S. Department of State “2018 International Narcotics Control Strategy Report,” 131.
32 These include Border Enforcement Security Taskforces (BEST), Integrated Border Enforcement Teams (IBET), and the Integrated Crossborder Maritime Law Enforcement Operations (aka “Shiprider”); see also the U.S. Department of State “2018 International Narcotics Control Strategy Report.”