Stopping the Flow of Fentanyl

Deanna Lee

You're listening to Policy Minded, a podcast by RAND. I'm Deanna Lee. About 87,000 Americans died from drug overdoses in the 12 months ending in September, 2024. That's a heartbreaking number, but the death toll is down from 114,000 fatal overdoses a year earlier, a sign that some progress has been made in the battle against illegal opioids. But there's still a long way to go. Overdose remains the leading cause of death for Americans between the ages of 18 and 44. In today's show, we're going to discuss this ongoing crisis in America, focusing on the supply of fentanyl and other illicit synthetic opioids. The Trump administration, in fact, has identified this issue as one of its top priorities, emphasizing the need to stop the flow of fentanyl over U.S. borders. Joining us today to talk about this is RAND's David Luckey. He's a senior researcher at RAND and a retired Marine Corps officer with more than a decade of service in the federal government. Dave, welcome.

David Luckey

Thanks so much for having me.

Deanna Lee

In 2022, you helped lead a research effort initiated by a bipartisan commission on combating synthetic opioid trafficking. We'll get into the findings and recommendations from that research shortly. But first, let's start with the basics. What do we mean when we say synthetic opioids and what makes them different?

David Luckey

Yeah that's a great question. Synthetic opioids are opioids produced chemically, they're synthesized chemically unlike heroin which starts its life as a crop, opium poppy, and the difference, the primary differences are the cost of production, the ability to produce year round without waiting for an annual crop. The ease of the chemical synthesis involved is another aspect that makes fentanyl so dangerous.

Deanna Lee

And is it true that they're more lethal as well?

David Luckey

Fentanyl is 50 times more powerful than morphine, so yes it takes a smaller quantity of fentanyl than for example heroin for the desired effect.

Deanna Lee

Okay, let's talk a little bit about the commission that I mentioned and the research effort that you led. How did you approach understanding such a wide-ranging problem?

David Luckey

So the commission's charter was developing a strategy on combating synthetic opioid trafficking. It was determined that the effort should be expanded beyond just the production and distribution of illegal fentanyl. And because of that, we accounted for the other two primary aspects of this problem, those being demand reduction and harm reduction, and we focused on looking at the problem holistically and as I mentioned, developing a strategic response.

Deanna Lee

And is that holistic approach what made this so unique? Had anything like that ever been done before?

David Luckey

I don't know if there was ever a commission specifically to look at illegal fentanyl trafficking, but I will suggest the way that the commission was created was, in my opinion, the most effective way of doing it. And by that, I mean the commission was bipartisan. There were sitting members of Congress from both parties. In fact, one of the co-chairs was a Republican and the other was a Democrat. There were sitting members of Congress from both chambers. It was bicameral. There were two commissioners from the House and two from the Senate. In addition to that Congressional representation, there were seven commissioners from the executive branch of the federal government, and they came from the departments and agencies most closely related to this topic. So, for example, there were representatives from the Drug Enforcement Administration. There were commissioners from the Departments of Defense, Homeland Security, Treasury, Justice. There was a commissioner from the Intelligence Community. So it had very broad support from the executive branch and there were also four commissioners appointed by the leaders in Congress for their specific areas of expertise. So the commission was established with a broad mandate, as you mentioned, but it consisted of commissioners who could address all the various topics involved.

Deanna Lee

Now, you said the commission's report also looked at the demand side of the opioid crisis and explored other aspects, but we're going to focus our conversation today on the supply side. What were the biggest challenges that you identified when it comes to curbing the supply of fentanyl and other synthetic opioids in the U.S.?

David Luckey

Some of the major problems with fentanyl compared to crop-grown drugs is the fact that they can be produced 365 days a year. They're very inexpensive to produce. The chemical synthesis required to produce them is fairly easy. And it takes so little fentanyl compared to heroin, for example, to achieve the desired result by users. All of those things add up to making it a much more confounding problem.

Deanna Lee

Is there a solid evidence base to understand how much and exactly how these substances may be coming into the United States, either over the southern border or from China, for example?

David Luckey

Yeah, initially with the resurgence of fentanyl in approximately 2014 or 2015, finished fentanyl was being mailed through the international postal system and through express consignment carriers directly from production in China to wholesalers and retailers and individual users in the United States. In 2019, China scheduled all fentanyl and fentanyl analogs, and with that scheduling, there's been a tremendous reduction in finished fentanyl from being sent from China directly to the United States. However, China hasn't stopped producing the precursor chemicals and shipping those precursor chemicals necessary for fentanyl production to transnational criminal organizations in Mexico, primarily the Sinaloa and Jalisco cartels. So that continues. What we've seen since China scheduled fentanyl is these Mexican transnational criminal organizations are producing fentanyl in Mexico and primarily shipping that finished product across the southern border into the United States. These shipments, while we don't know exact numbers and quantities of these shipments, it's illegal activity, nearly impossible to track, what we do know is how much is being interdicted at the border, for example. And what we've seen generally over the past few years is primarily these interdictions are occurring at ports of entry, land ports of entry and recently primarily in Arizona and secondarily in California and then throughout the rest of the ports of entry. And these shipments are primarily, I think approximately 80%, of those interdictions taking place, are with U.S. citizens transporting these illegal drugs.

Deanna Lee

We talked a little bit about fentanyl precursor production and what a challenge that is for the U.S. So let's consider a hypothetical. What might happen if China were to restrict fentanyl precursor production?

David Luckey

That's a great question. These chemicals as I mentioned are legal chemicals they're regulated but they're legal chemicals and they're fairly widely available. In addition to just precursor production, we've also seen an uptick in pre-precursor production and what that means is chemicals being used to produce the precursor chemicals which are then used to produce finished fentanyl. But back to your question, so if China were to curtail production, it's likely that other nations could step in and fill that void. In particular, India is a good example. India has a very large chemical production, not as large as China's but extremely large, and likely less well-regulated even than China's chemical production is. And so that's why these unilateral, multilateral, and bilateral efforts are needed. For example, greater diplomatic efforts with India now before they've started producing and specifically shipping these precursor chemicals to transnational criminal organizations primarily in Mexico. We could get ahead of that by increasing diplomatic and other efforts now.

Deanna Lee

Let's talk a little bit about the solutions or the potential solutions to this problem. What specific recommendations came out of this research effort? Or what are the biggest keys to addressing the fentanyl supply?

David Luckey

Yeah, well, supply reduction is only one part. There are actions the United States can take to disrupt this supply. The reduction of supply of illegally-manufactured synthetic opioids has to be part of a larger comprehensive policy. And that comprehensive policy should consist of unilateral, bilateral, and multilateral actions taken by the United States. Reducing fentanyl supply requires a multi-dimensional approach. That involves not just interdiction at the border, but coordinated efforts with law enforcement, as well as previously mentioned, restricting the distribution of chemicals needed to manufacture this drug. And disrupting the online sourcing and the actions taken by these criminal organizations is critical in reducing the supply.

Deanna Lee

I believe in the report, it was characterized as a whole-of-nation effort, correct? It sounds like it's maybe even beyond a whole-of-nation effort, it's an effort that involves partners in other countries as well.

David Luckey

Absolutely. The actions required to resolve this crisis cannot be performed by the United States alone. We must have partners in this effort, specifically working diplomatically with Mexico and China to curtail those countries' involvements in this effort, as well as working with nations that are or soon might be experiencing a crisis like we have in the United States. By allying with these other nations, I would suggest we can bring greater results through coordinated efforts. Specifically, Canada, for example, is experiencing the second-largest fentanyl crisis after the United States. Working diplomatically with Canada to locate common ground in this effort, put pressure on, as I previously mentioned, Mexico and China, to curtail their production of finished fentanyl in the case of Mexico, and precursor chemicals in the case of China should assist and and allow for a greater and quicker resolution of the various aspects involved in this crisis.

Deanna Lee

Since you mentioned other countries, I want to ask you about an interesting piece you co-wrote last year about how, perhaps ironically, the U.S. might actually be able to learn from China's history, starting in the early 19th century, of struggling with opium. Can you tell us about some of those lessons?

David Luckey

While the world was a dramatically different place 100 or 200 years ago, some of these same factors are with us today, that being substance and opioid use disorder. As the United States is dealing with this problem today, I think there's perhaps a great deal we can learn from the opium problem that China had, specifically ways to deal with folks with substance use disorder. Again, as the Commission report laid out, curtailing the supply isn't going to resolve this problem. It's going to take concerted efforts of not only reducing the supply, but reducing the demand and the harms from these illegal drugs. And the commission determined that reducing demand is paramount in this effort. And China was able to reduce that demand and while the specific aspects of how they did that should not necessarily be replicated, I think what we can learn is that by caring for those with substance and opioid use disorder, that will naturally curtail supply.

Deanna Lee

So we talked a little bit about that whole-of-nation effort. Can you talk about what that might look like from the supply side of things?

David Luckey

Absolutely. This effort requires coordination between not just federal law enforcement organizations such as Customs and Border Protection and the Coast Guard, but also with state, local, tribal, territorial law enforcement agencies. Once these illegal drugs enter the United States, it's the responsibility of those state, local, tribal, territorial law enforcement organizations. And there is a program in the United States called the High-Intensity Drug Trafficking Area Program. There are these high-intensity drug trafficking organizations known as HIDAs in 33 regional areas across the United States and it's their responsibility to coordinate federal, state, local, and tribal territorial efforts in this space. The Commission determined that the program is working well. And likely should be increased because of the benefit this program brings in reducing the supply of these illegal drugs.

Deanna Lee

The research we've been discussing today was published a few years ago. I'm wondering about the progress that has been made since that time. For example, at the top of the show, I mentioned that we saw a drop in overdose deaths recently, which is good news, but do we know to what we can attribute that reduction?

David Luckey

Yeah, unfortunately there's no comprehensive answer to that question, however there are some actions that have been taken that I would suggest directly reduce those deaths. Things such as naloxone and fentanyl test strips by allowing people using drugs to test those drugs for the presence of fentanyl before ingesting them can save lives. By using naloxone for people who are experiencing overdose directly saves lives. So those are two aspects of a much larger body of effort that's underway again in all three of these areas, supply reduction, demand reduction, and harm reduction. Additionally, since the Commission's report came out, there have been various laws passed that I would suggest have had tremendous benefit and some of these laws are the Rural Opioid Abuse Prevention Act, the Fentanyl Results Act, and the End Fentanyl Act, and the Fend Off Fentanyl Act. And all of these laws, the goals of all of these laws is to reduce deaths from fentanyl overdose and poisoning.

Deanna Lee

And I'm curious, have these policies been pretty broadly supported?

David Luckey

Yes, well, they were bills passed in the Congress and signed into law by the President. So there has been a strong bipartisan and administration support of these acts. And let me step aside for a minute and just say that there's general consensus that we have an opioid crisis in this country. This isn't a political issue. You know, anytime you have a situation where tens of thousands of people are dying a year, it raises people's awareness. Where I think there are differences of opinion is on ways to resolve the crisis. And as the commission laid out and I've mentioned today, resolution of this problem will take efforts across all aspects of the problem. There's not a single silver bullet that will solve this problem and in fact wicked problems such as this fentanyl crisis cannot be solved, there is not a solution to this problem there are only better or worse ways at getting at resolving various aspects of the problem and that's why this problem has confounded so many people for so many years. Our dealing with fentanyl today is not so different I would suggest than dealing with methamphetamines or cocaine or heroin. And while the crisis with fentanyl is more acute than we've seen in the past, the various aspects attempted in those previous efforts that have proven unsuccessful I would suggest should be looked at, and other than trying to evolve the actions that were taken in the past in efforts at resolving the problem, I suggest we need a holistic revolutionary approach and looking at and understanding the problem differently.

Deanna Lee

Are there any policies on the horizon or anything that's currently being considered that it might be worth talking about?

David Luckey

Well, I know there are various efforts underway in both the House and Senate to draft and hopefully pass additional legislation on this effort. I'm not gonna get into those details right now, but this is a problem, as you mentioned at the outset, it's the leading killer of Americans aged 18 to 44, greater than gun violence or car crashes or individual disease. And so folks understand the magnitude of the problem. It's just in finding better ways at resolving it where I suggest we need to put our efforts.

Deanna Lee

So what do you want to make sure our listeners understand about this issue? I'm sure many of them have experienced, either themselves or with a friend or a family member or a loved one, this crisis has touched so many people in this country. What do you wanna make sure that people know, or maybe if there's something you wanna clear up that tends to be misunderstood about this wicked problem, as you say?

David Luckey

That's an excellent question. RAND found in other research that approximately 40% of Americans know someone who has died from this crisis. And in fact, two of the 15 commissioners on that Commission had experienced direct loss. One of the commissioners lost a son and another one of the commissioners lost a nephew. And as we analyzed and discussed and debated this problem three years ago, it became very personal to us, as it should be for for all Americans because this is a problem that is happening to our families and our friends and our co-workers. It's not just a theoretical problem. People are actually dying from this every day and continuing to die from this everyday. In addition to the horrors of death, this crisis affects us economically. It's been estimated that the death and destruction from this crisis costs hundreds of billions if not up to a trillion dollars a year and these are monies that could be spent on other activities. Specifically related to this, for every emergency medical technician or law enforcement officer or emergency room nurse or physician involved in a fentanyl overdose, those activities could be spent doing other things that protect our citizenry.

Deanna Lee

Sure. And you're absolutely right. It's personal for many people and it's personal to me as well. So thank you for the work that you've done on this. So before we go, let's shift gears and talk a little bit about some exciting news that you're involved with. RAND recently announced a partnership with West Virginia University. Can you tell us a a little bit about it?

David Luckey

RAND and West Virginia University have partnered to bring benefit to the rural communities in West Virginia. The entire state of West Virginia is considered rural and problems afflicting rural Americans are tremendous. By all accounts, there are perhaps 50 million rural Americans, which is about one seventh of the population of the United States. And problems afflicting rural communities are generally compounded by one another. For example, a lack of educational opportunities, a lack of training opportunities, a lack of opportunities in the workplace. And RAND and West Virginia University have partnered initially to assist in areas of workforce development. Specifically, we're going to be looking at things such as apprenticeship programs, stackable credentials and career pathway mapping, continuing technical education, all with the intent of improving the lives of disadvantaged West Virginians. These efforts are intended to grow beyond just this initial list of workforce development, and grow into a much broader series of research and analysis to bring improvement to these folks' lives in areas such as opioid and synthetic drug use, opioid use disorder, substance use disorder mental and emotional health issues, poverty and homelessness, workforce development as I mentioned, education and training, foster care, critical infrastructure protection, improving access to the Internet and wi-fi, all things to bring benefit to those who need it most in our country. That's what this initiative is setting out to do.

Deanna Lee

And West Virginia is one of the states hardest hit by the opioid crisis, correct?

David Luckey

Absolutely. In fact, I would suggest West Virginia is at the epicenter of this current opioid crisis. Its state has realized the highest per capita deaths from overdose and poisoning from opioids and other illegal drugs. The aspects of the fentanyl crisis are felt hardest in West Virginia, which really led to the creation of this research entity, this partnership between West Virginia University and RAND, to start doing research and bringing actionable recommendations to improve the lives who have been hit the hardest from this.

Deanna Lee

All right, I think that's all the time we have for today. Dave, thank you so much for joining us.

David Luckey

Thanks so much, Deanna. It was a pleasure, and this is important information that folks need to hear, so I'm really glad that you're doing this.

Deanna Lee

And thanks to our listeners, you can find links to the research we discussed today at rand.org/policyminded. Thanks again to today's guest, David Luckey. This episode was produced by me, Deanna Lee. It was recorded by me and by David. Evan Banks edited today's episode. And RAND's Director of Digital Outreach is Pete Wilmoth. We'll see you next time on Policy Minded. RAND is a nonprofit institution that helps improve policy and decisionmaking through research and analysis.