What experts say can lower fentanyl use and overdose deaths

Colorado lawmakers want to stop the overdose deaths: the toddler who ingested fentanyl, the five friends who thought they were using other drugs, the teen who overdosed in her high school classroom.

As the drug overdose crisis reaches its worst point in years, a bipartisan group of state lawmakers introduced a bill March 25 that attempts to address fentanyl’s exponentially rising death toll.

But what do experts and drug research tell us are the most effective ways to stop this crisis?

Experts interviewed by The Denver Post said lawmakers and law enforcement need to think outside of the box when addressing fentanyl. The drug’s potency and the ease with which it can be made mean many tenets of mainstream drug enforcement policy won’t work, they said.

“Tackling this problem is going to require a lot of new ideas,” said Bryce Pardo, associate director of the Drug Policy Research Center at the RAND Corporation.

The bill introduced in the statehouse tackles the issue from both the criminal and harm reduction angle. The bill includes harsher penalties for people dealing fentanyl, a new criminal charge for distribution resulting in death and increased funding for overdose reversal medication, fentanyl testing strips and medication-assisted treatment in jails.

The bill has sparked criticism from law enforcement and harm reduction advocates alike.

Law enforcement officials want lawmakers to reverse a 2019 bipartisan bill that made possession of up to 4 grams of fentanyl a misdemeanor crime and make possession of any amount of fentanyl a felony. Harm reduction and criminal justice reform advocates oppose creating harsher penalties for drug crimes, citing research that longer prison sentences do not reduce overdose deaths.

Here’s what people need to know about fentanyl and how to best minimize drug use and overdose deaths, according to experts and academic research.

How is fentanyl different?

Illicitly produced fentanyl is different than other common illegal drugs in ways that make combatting it more difficult.

Most illicit fentanyl found in the United States can be traced to drug labs in Mexico and chemical suppliers in China, according to the Drug Enforcement Agency. That means that U.S. law enforcement does not have control over the sources of the drug. Past interventions in international drug sources — like the destruction of coca fields — are unlikely to work with fentanyl, researchers say.

“Today, it is possible to produce small quantities of fentanyl without specialized facilities or highly technical skills, allowing many different points of supply to emerge,” according to a 2020 paper by Pardo and University of Maryland professor Peter Reuter published by the Brookings Institute. “Therefore, the focus on production and trafficking of fentanyl are unlikely to generate a lasting disruption.”

A report by the congressionally convened Commission on Combating Synthetic Opioid Trafficking found that only 3 to 5 metric tons of pure fentanyl would satisfy the entire annual U.S. consumption of illegally supplied opioids. That’s a faction of the estimated 47 metric tons of heroin and 145 metric tons of cocaine consumed in the country in 2016. The smaller quantities and higher potency makes moving fentanyl much easier because smaller amounts can be concealed easily, or shipped through the mail.

“This devastating story is not leading to a happy ending. The difficult truth is that there is no easy solution to the synthetic opioid problem,” the commission’s report states. “The supply of illicit fentanyl cannot be permanently stopped through enforcement alone — only temporarily disrupted before another cartel, trafficking method or analogue steps in to fill the market that addiction creates.”

What are other states doing?

Nearly every state in the U.S. has seen a significant increase in the number of overdose deaths in recent years, driven primarily by fentanyl, according to data released in October by the Centers for Disease Control and Prevention.

Lawmakers in other states have introduced or passed bills to address fentanyl. In some states, like Florida and New Mexico, legislation has focused on decriminalizing fentanyl test strips, which are considered illegal drug paraphernalia in some parts of the country. In other states, including Wisconsin and Kentucky, lawmakers passed bills creating harsher penalties for fentanyl distribution. Texas lawmakers last year passed a bill that upped the sentence for fentanyl delivery or manufacture to a minimum of 10 years and a maximum of life imprisonment.

Other states have advanced promising innovations with treatment, said Alaina McBournie, a manager with Pew’s substance use prevention and treatment initiative. A program in Rhode Island pairs people hospitalized after an opioid overdose with someone with lived experience with addiction who can help them navigate the system, she said.

Internationally, the small country of Estonia in northern Europe has dealt with fentanyl for 20 years, Pardo said. Law enforcement busted two major sources of fentanyl in 2017, which temporarily disrupted supply, though data shows that many users simply shifted to other synthetic drugs. Estonia’s ability to significantly reduce fentanyl supplies may be difficult to replicate in the U.S., however, because it is a significantly smaller country with a population of about 1.3 million.

“We’re pretty much stuck with the fentanyl problem,” Pardo said.

How can police most successfully combat fentanyl?

Law enforcement has an important role in combating drug use and deaths, researchers said.

Police can play a key role in keeping fentanyl out of a local drug market by quickly intervening and arresting those bringing the substance into the community, Pardo said.

Once fentanyl is established in a market, however, law enforcement’s job becomes much trickier. Investigators should focus their efforts on the people doing the most harm by investigating drug deaths as intensely and quickly as a homicide, Pardo said. It is important that those responsible be held accountable quickly. The message from police should be that they will aggressively target dealers who are irresponsible in their handling of fentanyl and cause death, he said.

Police should also play a public information role and tell the community when fentanyl is found in seized drugs, Pardo said. Quickly alerting people that police found fentanyl in powder being sold as cocaine, for example, could prompt people who use cocaine to be more careful or test their drugs.

Traditional policing strategy includes driving up drug prices by reducing the supply through arrests and seizures, according to the Brookings Institute paper. That method can temporarily disrupt a market if a major supplier is disabled, but case studies show that the market adapts and new suppliers emerge.

“Given that fentanyl can be made from cheap and easily obtained pre-precursors, it is unlikely that traditional law enforcement or regulatory approaches aimed at producers will reduce imports,” the paper states.

Do longer prison sentences for drug charges impact drug use?

Researchers say there is little evidence that longer prison sentences for drug crimes prevent drug use.

“This is a natural reaction for society and lawmakers to say, ‘We want to put the squeeze on this,’ but you can’t arrest your way out of this problem,” Pardo said.

A study by the Pew Charitable Trusts published in 2018 compared states’ rate of imprisonment for drug crimes with three ways to measure drug use — self-reported drug use, drug arrests and overdose deaths — and found no statistically significant relationship between the factors, even when controlling for demographic variables.

“The findings… reinforce a large body of prior research that cast doubt on the theory that stiffer prison terms deter drug misuse, distribution and other drug-law violations,” the report states. “The evidence strongly suggests that policymakers should pursue alternative strategies that research shows work better and cost less.”

The severity of possible sentences has less of an impact on dealers’ behavior than the certainty that they’ll be caught, Pardo said, referencing a 2013 study.

Research also shows that people leaving incarceration are 10 to 40 times more likely to die of an opioid overdose than the general population, according to the federal Substance Abuse and Mental Health Administration. Incarceration of people with addiction — without providing treatment — is extremely dangerous and often leads to worse outcomes for that person, said Dr. Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health.

“While they are in prison or jail, they lose the tolerance they developed but they often have not been treated for the addiction,” she said. “So when they’re released, they relapse, but they have no tolerance and they overdose and die.”

What solutions do research support?

All three experts said expanding access to medication-assisted treatment, the overdose-reversal medication naloxone and testing strips are effective ways to reduce overdose deaths. Medication-assisted treatment is the use of medications that blunt opioid withdrawal symptoms, like methadone, combined with counseling and behavioral therapies.

“Medications for opioid use disorders are the most effective intervention that we currently have,” Volkow said.