The Opioid Epidemic Created by the Licit Drug Trade in the USA
In the National Drug Threat Assessment (NDTA) Summary 2015 of the DEA the number of drug poisoning deaths for the period 2008 to 2015 by medications which include controlled prescription drugs (CPDs) were 200,113 persons, for heroin 51,506 persons and cocaine 39,890 persons. Licit controlled and uncontrolled drugs are then the major cause of drug poisoning deaths and in this category CPD opioids are the dominant cause of drug poisoning death. For the period 2007 to 2013 drug poisoning deaths caused by CPDs opioid analgesics was 110,615 persons with heroin 30,338 persons and cocaine 34,203 persons. The opioid epidemic in the USA has then two realities that impact the drug market for opioids: CPD manufactured, distributed and retailed via a regulatory structure and the illicit market where heroin, and licit and illicitly manufactured opioids are marketed at the wholesale and retail levels. The DEA in its 2017 NDTA states: “The threat posed by controlled prescription drug (CPD) abuse is prevalent. Every year since 2001, CPDs, especially opioid analgesics have been linked to the largest number of overdose deaths of any illicit drug class, outpacing those for cocaine and heroin combined.” Again the 2017 report states: “the number of individuals reporting current use of CPDs is still more than those reporting use of cocaine, heroin, amphetamine, MDMA, phencyclidine (PCP) combined” The discourse of the opioid epidemic in the USA is then aggressively seeking to mask the reality that the opioid epidemic is in fact the failure of the regulated licit market for opioid analgesics. A licit drug trade fostered by deliberate attempts to subvert the regulatory structure combined with the failure to regulate and the intervention of ruling politicians to weaken the regulatory structure. These measures have unleashed on the US population a CPD opioid addiction problem which has spawned an illicit opioid market joined at the hips with the CPDs supplied opioid drug market. Where demand for opioids generated by supply from the licit market is now entering illicit opioid markets seeking affordable and regular supply. With the Mexican traffickers responding to this demand by raising the purity and lowering the price of its heroin to ensure that illicit opioid markets under their control can hold on to and generate new customers on a sustainable basis. This strategy drives the sale of fentanyl on illicit opioids markets by the Mexican traffickers today.
On the extent of the CPD opioid abuse problem in the USA the 2017 NDTA states: “Survey, treatment and demand data indicate epidemic levels of CPD abuse. More individuals report current use of CPDs for cocaine, heroin, and methamphetamine combined, making CPD use second only to marijuana. In 2014, there were 128,175 treatment admissions to publicly-funded facilities for non-heroin opiates/synthetic abuse, a decrease of approximately 32 per cent since 2011, when 188,920 admissions were reported.” The use of the generic concept controlled prescription drug (CPD) is another instrument of the discourse to mask the reality of the epidemic spawned by the licit drug trade in opioid analgesics. The use of persons admitting themselves to interventions that are publicly funded for treating with opioid addiction is also a very limited measurement tool of the expanse of the use of and the number of addictions to opioids in the population of the USA. The explanation the DEA gives for the decline in persons presenting themselves for intervention programmes in public funded facilities is as follows in the 2017 NDTA: “This decline in part can be attributed to CPD abusers switching to heroin or other illicit opioids. Some CPD abusers, when unable to obtain or afford CPDs, began using heroin as a cheaper alternative offering similar opioid-like effects. Other reasons for the decline in admissions could include the success of Prescription Drug Monitoring Programs, pill abusers seeking treatment at private facilities and increased efforts from law enforcement and public health entities.” The DEA simply has no research backed explanation for the decline in admissions to publicly funded treatment facilities but it admits that the licit drug trade in opioids created demand for illicit opioids. This illicit demand in fact resurrected the heroin market of the USA in the 21st century constituting a gift to Mexican trafficking organisations. The 2015 NDTA on the issue of abuse states: “The number of treatment admissions to publicly funded facilities for non-heroin/synthetic opiates in 2012 was 36.5 per cent higher than the number in 2008; however the number of admissions declined from 2011 to 2012.” The political need to illustrate success in the opioid war therefore accounts for this discursive line which masks the reality of addiction on the ground, how the victims of addiction to opioids deal with their existential reality, how the state responds to their addiction and addiction driven behaviour and the expanse of demand for opioids in the US diet for drugs. The politics of reporting any decline is illustrated in the 2017 NDTA with Figure 18 titled “Number of Admissions to Publicly Licensed Treatment Facilities by Primary Substance, 2014” which covers the period 2009 to 2014 where 1,828,413 persons (an average of 130,601 persons per year) were admitted for treatment with heroin as the primary substance and 949,833 persons (an average of 67,846 persons per year) were admitted for treatment with non-heroin opiates/synthetics as the primary substance. One cannot conclude from these admittance statistics that heroin abuse in the USA dwarfs CPD abuse as the DEA says no. What then is apparent for the period according to the DEA report is that more heroin abusers enter treatment facilities than CPD abusers which is linked to the reality that one is a licit product whilst the other is illicit and heavily policed and sanctioned. CPD abusers therefore show an inclination to evade treatment facilities which impacts the annual number entering treatment. This attitude flows from the discourse of licit opioid use unleashed in the USA which promises to banish pain with very little threat to the welfare and well-being of the user. A discourse which denies the pharmacology of the opioid to enable maximisation of profit for licit enterprises.
All licit and illicit drug markets are driven by the nexus of supply and demand especially so in the drug business where supply begets demand. The supply side of the licit opioid drug market then impacts both the licit and illicit opioid markets of the USA. The supply side of the CPD market is potently illustrated in the 2016 NDTA figure 36 “Number of Dosage Units of Opioid Narcotics Disbursed to Retail Level Purchases by U.S. Distributors 2006-2015 (in billions)” where for the period 147.5 Billion units were disbursed to retail level purchases. When the figure for 2016 is added it rises to 161.5 Billion units. For the period 2006 to 2016 the monthly average is 14.68 Billion units. With an estimated 2017 US population of 325.3 million persons the number of dosage units disbursed at the retail level per monthly average amounts to 45 dosage units for every man, woman and child in the USA on a monthly basis. This not the supply side of a licit regulated opioid market where a drug is being prescribed to deal with a medical problem fully cognisant of the threats posed by the drug to the user and the limitations of the drug in dealing with the problem it was prescribed for. This is a licit regulated market where regulatory agencies have failed to prevent the deliberate strategy to evolve a licit drug market into a hybrid licit drug market. Where the pursuit of the maximisation of profit has subverted regulation and breached the safety of end users of licit opioids. The 2016 and 2017 NDTA report that 99.2 million dosage units were lost for the period 2009 to 2016 which potently illustrates that the epidemic is the product of and fed by the licit supply of opioids acquired through the regulatory process of prescription and purchase of the prescribed opioid from licit regulated suppliers. Prescriptions and sale of opioids via the regulatory process is maintained by the distributors of the regulated opioids and by the manufacturers who by their production volumes determine the nature of supply. A willingness to distribute licit opioids to regulated outlets in volumes which clearly outstrip the population of the catchment areas which the regulated point of sales serve can then potently indicate the drive for profit maximisation has then breached the regulatory structure.
The structure of prescriptions for CPDs are then illustrative of not only the prescribing habits of the USA but also of the nature of the abuse of CPD opioids and the failure of regulation of this licit drug market. In the 2017 NDTA there are 4 opioids (hydrocodone, oxycodone, tramadol and codeine) in the prescriptions issued for the top 10 CPDs with hydrocodone and oxycodone being the number 1 and number 2 drug prescribed respectively. In the 2017 NDTA figure 24: “Top 10 Controlled Prescription Drugs (CPDs) Written in Millions of Prescriptions, 2011- 2016” presents the sum of prescriptions written for the 4 opioids by year and for the period. By year for the period 2011 to 2016 is as follows: 2011-269.3 million, 2012-271.5 million, 2013-263.8 million, 2014-255 million, 2015-236.9 million and 2016-223.8 million. The total prescriptions for opioids within the top 10 CPDs for the period were: 1,520.3 million. By prescriptions for the 4 opioids of the top 10 CPDs prescribed for the period is as follows: Hydrocodone-746.1 million, Oxycodone-360.3 million, Tramadol-257.2 million and Codeine-156.7 million. The basis of demand in the USA for CPD opioids is a predilection to immerse the population of the USA with prescriptions for controlled opioids particularly hydrocodone and oxycodone. Which is illustrated by the number of dosages of controlled opioids sold on the licit retail market seen in figure 25 of the 2017 NDTA: “Top 10 Controlled Prescription Drugs (CPDs) Dispensed in Billions of Dosage Units, 2011-2016”. By year the dosage units of controlled opioids dispensed were as follows: 2011-19.7 billion, 2012-19.8 billion, 2013-19.2 billion, 2014-18.4 billion, 2015-18.3 billion and 2016-16.3 billion. The total number of dispensed units of controlled opioids for the period 2011 to 2016 was 110.7 billion dosage units. By controlled opioid the dispensed units for the period were as follows: Hydrocodone-47.8 billion dosage units, Oxycodone-26.4 billion, Tramadol-19.6 billion and Codeine-16.9 billion. Of the controlled opioids within the top 10 dispensed CPDs hydrocodone accounted for 43.17%, oxycodone-23.84%, tramadol-17.70% and codeine-15.26%. The decline in the number of dispensed controlled opioid dosages that commenced in 2014, continued in 2015 and heightened in 2016 is cited as a noteworthy development in the response to the opioid epidemic. But the volume of dosages of controlled opioids that were dispensed in spite of the reduction continues to drive demand and as a consequence addiction, overdoses and death is the result.
Prolific prescribing of controlled opioids then drives the dispensing of billions of dosage units of controlled opioids per annum which is the supply that relentlessly begets demand which is accommodated by the prescription pill mill, by acquisitions from licit holders of a supply of controlled opioids, by illicit acquisitions from the licit supply structure and by turning to illicit drug markets for supply of controlled opioids and/or illicit opioids as heroin. A single licit holder in a single family household can set in train the dynamic of use, abuse and addiction by persons who are not bona fide holders of prescriptions for controlled opioids. This is the product of the volume of prescriptions issued and the volume of dosage units of controlled opioids dispensed as a result per the population of the USA. The tsunami of supply has resulted in controlled opioids being the most available opioid on the market thereby limiting the level of demand for illicit opioids. For the level of demand for illicit opioids is directly linked to the dynamics of the controlled opioid drug market as the illicit opioid market has no dynamic unique to it as it is forced to respond to supply issues that arise in the controlled opioid market. The licit drug market has captured the illicit drug market seen in the fact that the retail price of diverted controlled opioids on the illicit market commands a premium on the streets that drives demand to heroin. Demand for controlled opioids outstrips that of heroin and those unable to tap into a supply line from the licit structure has to pay a premium on the streets. This is the product of the prescription and dispensing mills for controlled opioids in the USA. The regulatory framework for controlled opioids has been breached facilitating profit maximisation to the detriment of personal safety and well-being.
One instance of the power relations of a licit drug market that impacts the regulatory agency of the Federal government of the USA and its designated task under law was highlighted by a joint Washington Post and CBS “60 Minutes” investigation of the Drug Enforcement Administration (DEA). The investigation revealed that lobbyists hired by the US drug industry effectively lobbied Congress to have legislation passed in both the House and Senate that effectively reduces the ability of the DEA to prosecute particularly the distributors of controlled opioids for supplying these controlled substances to those empowered to write prescriptions for and dispense these opioids considered by the DEA to be sales to “shady” operations in other words pain pill mills and dispensaries. What is noteworthy in this affair is that the DEA and the Justice Department under the Obama administration did not object to the legislation to the Congress and reportedly neither to then President Obama who signed it into law. The licit drug business of the USA has then illustrated its power to coerce the DEA and the Justice Department of the federal government. In its quest to supply controlled opioids in an already oversupplied market without due consideration to the end use of the controlled substances they sold and the impact on human lives they then emasculated the already compliant DEA. Another potent lesson of the discourse of neo liberalism and its fetish of Homo Economicus in action. This is the behaviour in a licit drug market that is no different from that of the illicit drug market with one salient grave difference: the power wielded by the players of the licit drug market over the political institutions of the state. This is the disadvantage of the players of an illicit drug market when faced with competition from a licit drug market as in the opioid market of the USA.
The DEA approved the manufacturing output of controlled opioids as is their power under law that set the whole train in motion in the licit opioid drug market. The DEA then approved the manufacturing output that drove the marketing drive (supply begets demand) to have billions of dosage units of controlled opioids dispensed which means sale of the units manufactured under approval of the DEA. This tsunami of production/supply conjured up demand that evolved into the opioid epidemic which means greater demand and maximisation of profit. End use has nothing to do with this. Faced with the political blow back from the monster created the supply side players have indicated their power to subjugate the DEA further to ensure that the industry fully exploits the demand horizon generated by the opioid epidemic. In this quest the DEA, the Department of Justice and the elected politicians complied willingly and faithfully.
The political discourse of citing the illicit drug trade for the opioid epidemic is but another attempt to ensure that the licit drug market is made sustainable and remains dominant and hegemonic. Mexico and China are the villains of the piece and the DEA responds to the political discourse by showing what it’s doing to crack down on the illicit drug trade whilst the law that has emasculated its regulatory power over the licit opioid drug trade is still on the books in your face! The new buzzword is illicit fentanyl manufactured by the Chinese and the Mexicans sold on the streets of the USA not the hydrocodone and oxycodone manufactured in the USA and dispensed in billions of dosage units.
There are lessons to be learned on the nature of the war on drugs prosecuted by the USA and the nexus between the licit opioid drug trade and the state in the USA. The licit drug trade is relentlessly obsessed with maximising profit through maintaining the level of supply that begets the level of demand necessary to maximisation of profits. To accomplish this state regulation has to be complicit and servile whilst the illicit market must not be able to offer the same controlled opioids for sale at competitive prices. The manufacturers, distributors, dispensers and prescribers have then formed a supply cartel which determines the price of their products on the illicit market creating a price point where alternatives are sought for their affordability. The state has then to police the illicit market to ensure the sustainability of the hegemony of the cartel that runs the licit opioid market and the hegemony of the licit over the illicit market. Whenever the rules governing the use of drugs change enabling the creation of a licit market for a previously illicit drug the players of the licit market will inevitably move to dominate the illicit market and strive to create the supply side cartel of the licit market that dominates the licit market. And in this quest the intervention of the state is strategically necessary thereby setting in train the means to purchase political influence. This is the process that is being held up by the discursive agents of the war on drugs who continue to strive to dismantle this evolutionary process in the marijuana market of the USA. Specific states of the union have started the process whilst others have refused but most importantly the potent restrictions for the creation of the licit markets reside at the federal level. At present what exists is a stalemate which is hindering the evolution of the licit marihuana market but cannot destroy the changes made. But already in states involved in the process of creating the licit market the dynamic and the power relations of a licit market moving to dominate an illicit market with the other attendant realities are apparent.
The war on drugs in the USA shows the propensity to create licit drug markets that embody the basic operational strategies of illicit markets and much more importantly the players of the licit market exercise and exhibit the power to ensure the compliance and support of the state utilising the political mechanisms of the state. This power is exercised to the benefit of the players regardless of the reality of the pharmacology of the opioids they sell in relation to human consumption. A comparison with the opioid use reality of Europe on this note is instructive. The Europe Drug Report 2017 states: “Comparison with developments in North America is also relevant to an analysis of Europe’s opioid drug problem. A review of the data in this report suggests that, while the overall EU situation remains different, some parallels do exist. One difference between the two regions, is that in Europe, very few clients presenting for specialised drug treatment do so for addiction to opioid pain medicines. This probably reflects the different regulatory frameworks and approaches to marketing and prescribing that exist between Europe and the North America.”
It’s fitting to end with a quotation from the executive summary of the 2017 NDTA of the DEA as follows: “Drug poisoning deaths are the leading cause of injury death in the United States; they are currently at their highest ever recorded level and, every year since 2011, have outnumbered deaths by firearms, motor vehicle crashes, suicide and homicide. In 2015, approximately 140 people died every day from drug poisoning.” The licit opioid drug market is the largest single contributor to this human carnage on a daily basis in the USA. The victims of drug abuse and addiction are the collateral damage of the “War on Drugs”. The high cost of addiction levied on opioid abusers, their families and the social order must be factored into this discussion. For the daily life of addiction and its impact on the abuser, his/her children and family and the social order assaults the sanctity of human life and the need for human existence that is emancipated from the drive to satisfy the cravings of a chemically altered brain. A condition in which nothing is sacred your body, your life, your safety, your children and your family in your quest for the fix. A grave sentence to a netherworld where the collateral damage of the war on drugs is consigned to in the USA.