President Trump declared that opioids are now a “National Public Health Emergency.” At the same time he demonstrated his ignorance of important facts. That is likely the fault of Chris Christie’s chairmanship of the President’s Commission on Combating Drug Addiction and the Opioid Crisis. Only one of the Commission members, Dr. Bertha Madras, has any subject matter expertise. The other five are elected officials, all of whom have publicly demonstrated allegiance to the idea that the Drug War is the proper way to deal with an epidemic of overdoses.
To say that this is wrong-headed would be the observation of an astute student of the obvious. The War on Drugs was officially declared by Richard Nixon in 1971, but has been going on at least since the Harrison Narcotics Act of 1914. In a century we have experimented with banning one addictive drug, alcohol, only to discover that prohibition does not work. Yet politicians and their lapdogs in the press have slavishly insisted that if we do more of the same, we will eventually get a different result. Albert Einstein famously noted that this is one definition of insanity.
Widely distributing Narcan to drug addicts will probably save some lives when they overdose, but that’s like calling a wrecker to tow you to the tire store when one blows out after all four have been bald for a year. Sometimes you’ll get in safely, but other times you’ll end up injured or dead in an accident.
Dr. Madras is an expert in the cellular biology of addiction, but it is clear from her writings that she is most comfortable with remedies based in formulary controls, claims data surveillance, and education of physicians on reducing opioid risks. This top-down regulatory approach is shared by the congressman, state attorney general, and three governors who fill out the commission. In short, the Commission’s prescription was printed and signed before the Commission ever met. It completely ignores a century of experience in the field.
Opiates 101: A short course
In my 36 years in Anesthesiology, I became intimately familiar with the salient fact that all opiates are essentially the same drug. (See table) All work on the same receptor in the brain. All depress breathing so that in an overdose, the victim completely forgets to breathe until he is completely dead. All cause constipation, nausea, and vomiting. All change how one sees the world, and once your body is used to them, they all cause horrible withdrawal symptoms.
The only material differences between opiates lies in how quickly their effects start, how long they last, and how the drug is administered. In a sense, Remifentanyl is short acting Fentanyl, while Morphine, Heroin, and Dilaudid are delayed release Fentanyl. Oxycodone is essentially an oral form of Morphine. I could go on, but you get the point.
Knowing those facts made it easy for me to administer literally gallons of opiates safely. Had Heroin been legally available, it could have joined Fentanyl, Morphine, and Dilaudid as my front-line drugs for pain. After all, it has the same onset, duration, and side effects as Morphine and Dilaudid, with potency between them.
History 101: Why opium was banned
By now it should be painfully clear that there is no medical reason whatever for Heroin to be banned. It’s a good drug with definite medical utility. And Fentanyl has proven itself to be a very good drug since it was introduced into clinical medicine over fifty years ago. Yet suddenly there are wild cries to eliminate a “public health emergency” from a drug we’ve used safely for decades. Why should this be?
Opium has been used for both intoxicant and medical purposes for as long as we can trace history. It is an extract from a pretty flower that grows wild in many countries. It dulls pain by working more effectively at the endorphin receptor than endorphins, which your brain makes. As long as the strength of the drug is known, it is extremely safe. But do-gooders can’t leave well enough alone. Could it be they see some benefit for themselves?
Opium has been a cash crop for millennia, but by itself isn’t that highly profitable since harvesting and refining it is inexpensive. An addict can easily be supplied for a couple of dollars a day. A supplier needs a large market. Or he can have a smaller market at a higher price.
Our current obsession with the bad habits of others took full flower at the pen of William Randolph Hearst. During the building of the Trans-Continental Railroad, large numbers of Chinese laborers were imported. They took their one day a week off in the nearest shanty town where many smoked opium, got high, and slept it off. Hearst was a blatant racist with the largest megaphone in the country, the Hearst newspapers.
His hatred for the “coolie” sprang vividly from the headlines, cartoons, and editorials of his papers. Soon the “opium fiend” was a matter of public condemnation, even though the demon created in the printed word never existed, since opium does not lead to aggressive behavior. Shortly Congress passed the Chinese Exclusion Act of 1882, which prevented further Chinese immigration.
This did not end the frenzy. In 1914 Congress passed the Harrison Narcotics Act, again in the complete absence of evidence that individual consumption of narcotics caused harm to those not engaged in its use. Further, many, in the footsteps of the “coolies,” were able to use the intoxicating drug and continue to live a productive life.
When Harry Anslinger became the first Director of the Federal Bureau of Narcotics in 1930, the War on Drugs (by other names) became fully fledged. Never again would the wisdom of the effort to stamp out drug abuse be seriously questioned in the halls of power. Prohibition of one intoxicant, alcohol (1920-1933) was extended to other intoxicants, the opiates. Unlike alcohol which is consumed across wide socioeconomic classes and has been released from constitutional imprisonment, opiates remain the forbidden fruit.
The benefit of prohibition: Risk premium
While it is clear that, in the absence of proper medical indication, opiates are detrimental to well-being, addicts who are maintained on their meds are no threat to society. Many are able to function at a high level. So what benefit arises from prohibition? As James Carville famously said, “It’s the economy, stupid!”
When intoxicants are prohibited, a “risk premium” is created.
A risk premium is the return in excess of the risk-free rate of return an investment is expected to yield; an asset’s risk premium is a form of compensation for investors who tolerate the extra risk, compared to that of a risk-free asset, in a given investment.
When drugs are legal, there is no legal risk, and the cost to the consumer is the basic economic cost of the steps of production and distribution. As we noted earlier, this is less than the cost of your daily Starbucks latte’. It’s enough for a basic business but simply lacks the margin to support a criminal enterprise.
When drugs are illegal, a market still remains, since a significant portion of the population has wanted intoxicants throughout history. But now there is a notable risk to supplying the demand. So price increases to cover that risk. The curbside pharmacist has to get his supply somewhere. His supplier has the same problem, so the price goes up more. Now the customer has a problem.
If he’s going to empty his wallet to pay for all that risk, he wants a real bang for his buck. After all, he could end up in jail, too! This potency requirement raises the price on the other steps… again. It’s a vicious cycle. What started out as something cheap has become very expensive. And now there is profit for criminal enterprises.
Those enterprises will want to protect their turf from competition, and now we see violent crime start to appear around the drug trade. Customers who become addicted now have to find ways to support their habits, and various other crimes become common. Note that every level of crime was absent in the open trade for opioids. As soon as drugs became criminalized, bigtime crime moved in, because prohibition creates profits for them.
One more problem arises. How does a dealer keep his customers? He has to provide high quality product. This was demonstrated very well in the late 1960’s when Laotian General Ouana Rattikone marketed “999” heroin. It was a very consistent product so that a safe dose could easily be administered. When competitors made more highly refined heroin, he upped his game and produced “Double Uoglobe Brand” heroin. Reliable quality led to large sales.
Rattikone was in a protected area. Your distributor can’t do the same thing without attracting attention. But he can mix his product with other things. If he cuts it with inert materials, he can spread it further, but competitors will attack his poor quality. On the other hand, if he adds something a bit more potent, such as fentanyl, he will give the appearance of a better product.
Unfortunately, this competitive commercial response is now being seen in multiple markets with radically differing amounts of fentanyl. Now each addict is taking on a new risk every time he administers a dose. It may be worthless or it may completely stop his breathing until he is completely dead.
What if we legalized heroin?
Let’s review the chain of events. Prohibition introduces a risk premium, making crime pay. It also prevents the customer from knowing what dose he is getting. Many users will get overdoses, and many will die. Should we be surprised when that is today’s headline?
Suppose we legalized drugs? Apologists for prohibition claim we’ll see more addiction and more deaths. Instead “we need more detox and rehab programs.” Should we be surprised that this approach is promoted by people who profit from those programs?
Fortunately, we have laboratories that show what works. One of them is called Portugal. There, heroin was made legal in 2001. Sixteen years have shown that overdose deaths have almost vanished.
Addicts are maintained on steady doses of drugs they get for free from clinics. The total cost is less than that latte’ we mentioned earlier. And, curiously, addicts are slowly weaning themselves off of opioids in an average of ten years.
Imagine that! When they don’t have to resort to crime, addicts are able to maintain relatively normal lives and then act in their own self-interest. And no funds are diverted to unnecessary detox and rehab programs. And, by the way, no funds are spent on expensive drug interdiction efforts. No undercover cops infiltrate drug rings, because there aren’t any.
Suppose the United States was to do this? Our expensive rehab programs would go away, allowing money to be spent where it can actually do some good. But more important, the profit that fuels the Mexican drug cartels would dry up. We wouldn’t have Border Patrol agents running up against heavily armed drug gang members. There will be no need to prosecute the next El Chapo, because he won’t get rich enough to matter or to export his crime to the US.
What’s not to like?