It’s the economy, stupid: fentanyl, drugs, and accumulation

The opioid epidemic cannot be understood through medicine or morality. It is an economic phenomenon that cuts across legal and illegal markets, pharmaceutical industries, and criminal organizations. Fentanyl made it possible to reduce costs, expand supply, and massify consumption. When pain becomes a business, dependency ceases to be a problem and turns into an opportunity.

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Fentanyl is one of the most widely used analgesic and anesthetic drugs worldwide. Derived from opium, it was developed by the Belgian pharmaceutical company Janssen in 1960 and began to be used three years later across much of Europe.

As one of the most potent opioids used in human patients, doctors and scientists began experimenting with fentanyl and applied it for several years in combination with other drugs.

The goal was to find a medication capable of producing total anesthesia superior to anything available at the time. Paradoxes of chemistry and money. Many years later, other people—some perhaps with university degrees—also experimented with fentanyl and other drugs.

As with other opium-derived drugs, physicians and legislators in the United States, aware of the addictive potential of these substances, initially opposed the use of fentanyl, since it is one hundred times more potent than morphine. Even so, Janssen began the approval process in the United States and, after several negotiations and a few minimal concessions, secured the support necessary to obtain authorization.

Fentanyl began to be used in large quantities as an anesthetic and analgesic in cardiac and vascular surgeries, replacing morphine, which until then had been one of the most widely used medications for such procedures worldwide.

In little more than ten years, fentanyl sales increased tenfold and produced what happens with any drug that quickly captures the attention of physicians and entrepreneurs: the search for new drugs.

IT’S NOT JUST FENTANYL

In a very short period of research, pharmaceutical companies discovered so-called “super-fentanyls”: opioids up to ten thousand times more potent than fentanyl, used to anesthetize large wild animals such as moose and elephants.

The first was carfentanil, an opioid employed to anesthetize elephants or bears, which in 2022, in the San Martín district (Buenos Aires, Argentina), was used to increase profits in cocaine sales and ended up causing the deaths of at least twenty-four people.

Following the discovery of superfentanyls, pharmaceutical companies introduced fentanyl patches—the first of their kind—and transmucosal fentanyl, which could be described as a “fentanyl lollipop.”

Paradoxes of candy. The fentanyl lollipop was conceived as a preoperative anesthetic for children. It was also confirmed that fentanyl, carfentanil, and other derivatives could be incorporated into food or dispersed in the air and produce the same anesthetic effects.

This last development attracted the attention of the armed forces for possible use as an anti-terrorism agent, as occurred during the Moscow Dubrovka Theater hostage crisis in 2002, when Russian security forces dispersed carfentanil via gas grenades to incapacitate both the terrorists and the hostages.

In the early 1970s, barely five years after fentanyl was authorized for use in the United States, health authorities recorded the first cases of overdose leading to severe respiratory crises, apnea, and death.

Medical personnel are often the first to learn about and experiment with new drugs, but they are also among the first to misuse and illegally consume them, due to early access.

During the 1980s, with the emergence of new derivatives and new methods of administration, opportunities for opioid consumption outside any medical indication expanded and, in a very short time, reached the entire society.

By the mid-1990s, new methods appeared, and fentanyl pills and nasal sprays represented an exorbitant leap for both the pharmaceutical market and the illegal drug market.

For both markets, fentanyl is cheap to produce, extremely potent, and offers enormous profit margins, enabling experimentation and investment with the assurance of higher returns.

Concern among medical and governmental authorities regarding opioid misuse had been present for decades. The consumption of synthetic opioids—particularly morphine and heroin—had been documented for more than a hundred years, when dependency disorders became evident among veterans of the U.S. Civil War and the Franco-Prussian War.

Up to this point, the story seems medical. In reality, it has always been economic.

IT’S THE LEGAL ECONOMY, STUPID

In 1996, the American Pain Society, the U.S. chapter of the International Association for the Study of Pain, promoted the inclusion of pain as the fifth vital sign when assessing physical functioning, detecting disease, or monitoring recovery.

The peculiarity of this sign lies in its subjectivity. Unlike temperature, heart rate, respiratory rate, or blood pressure—measured through objective parameters—the level of pain depends almost exclusively on what each patient reports.

While opioid consumption has been sustained, albeit fluctuating, throughout history, in the 1990s—amid the American Pain Society’s aggressive campaign—a new wave of consumption began to be recorded, giving rise to the most recent major opioid epidemic.

The first had occurred eighty years earlier, also centered in the United States, and led to the first law attempting to regulate the production, commercialization, and consumption of opium, cocaine, and their derivatives.

The American Pain Society’s campaign—a nonprofit organization—was launched simultaneously with Purdue Pharma’s announcement of the release of OxyContin, an extended-release oxycodone-based medication.

Marketed as a drug with superior qualities, the company, together with an army of so-called pharmaceutical sales representatives, organized trips to paradisiacal cities, luxury hotels, and all-expenses-paid events to persuade physicians across the country to prescribe OxyContin.

In addition, they offered corporate gifts to those who issued the highest number of prescriptions, while salespeople earned bonuses of up to $80,000, even though their annual salaries did not exceed $50,000.

The campaign went viral through globally circulated publications—such as Time magazine—and relied on a letter from editors published twenty years earlier in a medical journal in Massachusetts, which claimed that hospitalized patients did not tend to become addicted when receiving opioids for pain treatment.

That brief letter was partially cited and distorted hundreds of times in medical publications. A lie—or at least a half-truth—repeated more than six hundred times ended up becoming truth. Controls on opioid prescriptions were relaxed, and in less than four years, the drug’s revenues rose from $45 million to $1 billion.

Alarm bells soon rang. First in local newspapers of small towns—where the state often pays less attention—and then, due to the magnitude of deaths, the issue captured the attention of authorities and national media. There are no exact figures, but investigations estimate that around 500,000 overdose deaths linked to OxyContin occurred over twenty years.

IT’S THE SAME ECONOMY

The period identified as the second wave of the opioid epidemic began in 2010, when heroin demand increased due to the reinstatement of controls on prescriptions for drugs such as OxyContin and the low prices offered by drug trafficking groups in Mexico, particularly the Sinaloa Cartel.

Heroin overdose deaths increased year after year as prices fell in the U.S. market. By 2015, these deaths surpassed those caused by the misuse of prescribed opioid medications, reaching the catastrophic figure of 17,000 deaths annually.

A large share of heroin overdose deaths occurred because drug traffickers in Mexico and the United States, like pharmaceutical companies, took advantage of fentanyl’s low cost and high potency and incorporated it into drugs such as heroin.

Fentanyl is to drugs what the steam engine was to the Industrial Revolution: with minimal quantities, production multiplies, costs fall, prices drop, and consumption becomes widespread.

The combination of fentanyl’s low cost and potency, together with declining consumer incomes and high overall demand for drugs—fentanyl is now mixed with cocaine, methamphetamines, and marijuana—gave rise to the third wave of the opioid epidemic in the United States, still ongoing and increasingly global.

In a short time, fentanyl overdose deaths doubled those caused by heroin, medications, and other contaminated drugs. From 2013 onward, the situation worsened year after year, eventually exceeding an average of 100,000 deaths annually—the equivalent, in terms of victims, of 515 Cromañón tragedies per year. The boundary between the legal and illegal economy lies not in methods, but in the legal status of the actors.

The increase in opioid consumption responded to multiple stimuli, including economic ones, as with any product in the legal or illegal market. Faced with rising demand, there are two possible responses: raise prices if supply is limited, or expand supply, maintain or reduce prices, and obtain greater profits through sales volume.

Since the pandemic years, drug production has grown uninterruptedly. The United Nations Office on Drugs and Crime (UNODC) estimated that in 2023, 3,708 tons of cocaine were produced—almost 34% more than in 2022—while the number of users of synthetic opioids has remained stable at between 60 and 61 million people. Production costs fell, prices—with some isolated exceptions—stagnated or declined, as did workers’ incomes worldwide.

The ability to increase supply and lower prices is increasing the number of users and people with substance use disorders. This situation places growing pressure on states, civil society, and the system as a whole. Resources allocated to address this phenomenon are scarce and, in the face of sustained demand growth, increasingly insufficient.

UNA POSIBLE SOLUCIÓN INTEGRAL Y SOBRE TODO, ECONÓMICA

Most current approaches are short-term and rely on incoherent or contradictory programs. In official documents, these programs often propose a comprehensive approach that includes medical, psychological, social, and family support for people with substance use disorders.

However, despite being the most frequently mentioned in international forums, television programs, or community meetings, they are also the ones receiving the fewest resources.

In many cases, this approach conflicts with strategies promoted by broad sectors of the judicial system and security forces. Focused on consequences rather than causes, the increase in their political and media influence, combined with the fragmentation of social phenomena, makes the implementation of coherent programs unfeasible—programs whose results can only be observed in the medium term.

The explosion of fentanyl as a raw material did not respond to moral issues, but to economic ones, within the context of massified consumption in a society with a profoundly unequal distribution of resources—one that accepts people based on their economic means to integrate, not on what is written in laws, treaties, or constitutions.

Designing, sustaining, and correcting—when necessary—prevention, recovery, and support programs for people with dependency disorders is indispensable and effective, provided they are integrated into broader projects aimed at guaranteeing dignified living conditions.

Without real redistribution of resources, without work, without access to rights, and without strengthened communities, any health or punitive strategy will continue to be little more than a belated response to a logic that has already decided who is expendable.

To achieve change—even within this system and with the aim of transforming it—the economy of communities and of people must be repaired. It is not only a necessity; it is a structural urgency.