A New Trade War with an Opium Component: Can the U.S. Opioids Crisis Be Solved by Banning Fentanyl in China?

Dear Editor-in-Chief

On April 1, 2019, China announced that all variants of fentanyl will be treated as controlled substances, after Washington urged Beijing to stop fueling the opioid epidemic in the United States. China criminalize the production and exportation of Fentanyl, a synthetic opioid which reminded people of trade wars that happened 170 years ago in China. The First and Second Opium Wars of 1840s and 1850s were launched by Great Britain to open a restrictive trading system imposed by China’s Manchu conquerors. For decades, Great Britain had been seeking wider markets for its expanding industrial production to pay for the raw materials and foodstuffs needed to support its industrialization. To pay for the tea, the British traded silver and a variety of goods. To offset the resulting silver drain, the British sold increasingly large amounts of opium, a drug long in widespread use for various purposes in China but illegal under the law of the Qing dynasty since 1799 (1). Concerned about the effects on society and the reversal of the silver flow in Britain’s favor, the Qing government forbade foreign merchants to bring it into China. It even burned the opium confiscated from British merchants at Canton, leading to war with the British and the opening of other Chinese ports to foreign merchants. An appeal to England’s Queen Victoria for relief from British sales of opium brought no relief.

Now, the United States of America is suffering from a trade imbalance with China and from imported Chinese Fentanyl. There was an increasing number of deaths due to illicit opioids after 2012. What caused the high number of fatal cases among illicit opioids users? Fentanyl and its analogues have a lower median lethal dose than other opioids, which makes it easier to have a fatal overdose. Lack of awareness about synthetic opioid potency, variability, availability, and increasing adulteration of the illicit drug supply poses high risks to individual users of illicit opioids. In addition, almost all the increases in overdose deaths are attributed to illicitly manufactured fentanyl, not to pharmaceutical fentanyl that has been misused or diverted, because the number of prescriptions for pharmaceutical fentanyl has remained relatively stable over the past decades. The illicit fentanyl possibly has been mixed with heroin and the risk of overdose increased substantially, because people have not been aware of it. Prescription Fentanyl, if it were available, would be at least safer than those illicit synthetic opioids. The low quality of illicit opioids (and their side effects) is more likely to be the reason for the increase in fatal cases of illicit opioids use. What drives the current trend of switching to synthetic opioids? Some states adopted an opioid-related policy like “Mill Pill” by controlling prescription opioids (2). Classical economic price and supply-demand theory indicates that reduced supply will cause a price increase when the demand is fixed. For opioids, their demand is fixed because it is a substance, and the opioids abusers are not sensitive to the price with the result that an increase in price cannot greatly reduce the demand for opioids. However, when the supply declines, the fixed demand will cause an increasing in price. Finding another cheap replacement is the only solution, if abusers cannot afford the high price one. Hence, a policy restricting prescription opioids serves to reduce supply, making illicit opioids including synthetic opioids like fentanyl a cheap replacement for prescription opioids. After a short period of decrease in opioids- related death, the total number of such deaths in the states that controlled prescription opioids continued to increase. Naturally, when individuals sought low-quality replacement opioids, they risked a more serious health outcome than if they had used prescription opioids. If this scenario is true, that means that a restrictive opioid policy indirectly “kills” the abusers. For substance abuse, it is very common that a policy plan to save lives may eventually hurt people. The Prohibition Era provides a good example. On Christmas Eve, 1926, in New York City, 60 people became ill and 16 died due to drinking smuggled alcohol contaminated with methanol (3). From 1916 to 1926, similar cases occurred in Norway during Prohibition there (4).

The current policy of criminalizing the sale of Fentanyl exported to the United States might not work because any effort to interrupt and suppress the illicit drug supply produces economic and logistical pressures favoring ever-more compact substitutes(3). It is the Iron Law of Prohibition. We should reduce the huge illegal import of illicit opioids without increasing automatically the supply from other countries. Back to 170 years before: Prohibition by the Qing dynasty of opium from British did not solve China's opium problem. China eventually let the provinces govern the opium trade, tax it, and get rid of opium by health promotion. Interestingly, a recent study from Colorado has shown that deaths from opioid overdose declined after legalization marijuana in Colorado (5). That could give us some inspiration on how to win this opioid crisis in public health. Only evidence-based harm-reduction and demand-reduction policies that acknowledge the structural determinants of health, such as health promotion, in treating the patient, will get us through this crisis.