The United States is currently suffering through the self-inflicted crisis of electing an authoritarian administration. Civil, legal, international, and diplomatic standards are routinely ignored and there seems to be no clear overriding strategy other than promulgating the autocracy. 271,000 government employees were fired, many leading experts in fields that ran counter to the autocratic myths, but most were loyal career government employees dedicated to serve the public. USAID – a government agency providing technical assistance and medical care in the developing world since 1961 was officially shut down by the Trump administration in 2025. USAID was credited with saving 92 million lives over 20 years and there is currently a tracker in place that estimates how many people will die as a result of the closure. It is clear the Trump administration is not afraid to be directly responsible for the deaths of tens of thousands if not millions of people. It might fit their American first narrative if there was any possible benefit to Americans. Their political calculus apparently ignores any goodwill effects of helping people and a national image unlike the usual totalitarian regimes.
Trump’s version of the War
on Drugs, is smaller in scale but probably much more deadly. Trump began sinking boats in the Caribbean and the Pacific Ocean
that he alleged were carrying drugs in September 2025. Since then, 35 vessels were struck or sunk
killing 123 people (1). There is ongoing
debate that this is not standard drug interdiction where drug smugglers are
stopped by the Coast Guard, arrested, and stand trial. This is unlawful killing of suspected drug
smugglers where the public is supposed to accept that the alleged intelligence
about whether they were smuggling drugs is accurate. Given this administration’s honesty track
record there is no way that should be accepted at face value. The Coast Guard’s own statistics suggests
that 25% of the vessels they board for the same reason are not carrying drugs. Even
if they were this is essentially executing people without due process for what
are non-capital crimes in the US.
In addition to the
strikes that are seen as criminal there have been 2 incidents suggesting
additional war crimes. In the first,
survivors of the first strike were killed while they were swimming in the
water. In the second, a strike was made
by a plane disguised as a civilian plane.
According to the Geneva Convention it is a war crime to feign protected
status and then attempt to kill, capture, or injure an adversary. This is known as perfidy and it is
accepted by the US. Like most activity
from this administration there appears to be no clear rationale for all this
activity and despite the outcry over potential war crimes – the actions
continue unabated.
I had plenty of
experience teaching diverse groups of students about the opioid epidemic from
about 2008 to 2020. Overdose deaths
were a proxy for the epidemic. The
initial part of that curve was due to excessive prescribing that was associated
with a pain as the fifth vital sign initiative. There were excessive and escalating
prescriptions for the treatment of chronic pain. In many cases there were diversions of these
drug supplies for non-prescription use.
In some cases, there were pill mills that specialized in writing
opioid prescriptions in great numbers.
They resembled medical practices from the turn of the 20th
century that maintained people in addiction rather than treating any specific
medical problems. As more prescription opioids were diverted it was more cost
effective to purchase heroin and that was the first significant change in consumed
opioid composition. By 2014 synthetic
opioids (fentanyl and carfentanyl) were
introduced into this landscape. They had
much higher potency than the usual prescription opioids and that led to more
drug overdoses. Countermeasures were
introduced including intranasal naloxone and fentanyl test kits. These are effective measures if available but
there is some misunderstanding by the public, who sees opioid users as risk
averse. They are not risk averse but
both countermeasures are useful in saving lives. The most effective life saving measure is
MOUD or medication for opioid use disorder including buprenorphine, methadone,
and naltrexone.
That brings me to a
paper on the sudden reduction in overdose deaths beginning in mid-2023 and
extending into 2025 in both the US and Canada.
During that time the overdose death rates dropped by 30%(3). The graph of that reduction is shown
below. The data is a combination of
confirmed data by the CDC and provisional counts and projections by NCHS for
the last two years. It is very similar
to the graphs generated by the authors in their report.
Both groups of
indicators of decreased drug supply (drug seizures and concentration and social
media posts indicating a drug shortage) correlated with a drop in drug overdose
deaths. By the end of 2024 the opioid
overdose death rates and concentrations has fallen by about 30% (see graph). The original paper plots both fentanyl
concentration in pills and powders as well as death rates).
What caused these
drops? The authors suggest several
possibilities. First, China acted
against the manufacture and sale of fentanyl and the precursors starting in
late 2023. That included online platforms.
There was a meeting between President Biden and Xi in November 2023 that
focused on law enforcement cooperation in this area. The authors suggest this is a low-cost
opportunity for China to get leverage in negotiations with the US. Second, US
drug interventions in Mexico may have reduced the supply, but the authors point
out that the DEA would have paradoxically claimed no credit in their reporting
but did credit the lack of precursors from China. These factors are strong arguments for supply
chain disruption as a cause of the drop in opioid overdose deaths.
Could this be a
generational effect? From a demographic
standpoint, the 25-plus year opioid epidemic represents an entire
generation. The succeeding generation
has seen the toll of these drugs as both mortality and morbidity. The younger generation has been noted to have
some sober initiatives and they are consuming less alcohol that their
predecessors. Is it possible that this subcultural movement is extended to
other intoxicants? The 0-25 year age
group typically has the lowest number of overdose deaths and by itself is
unlikely to account for the decrease.
The authors suggest
three implications of their paper.
First, that dealer level interdiction on the street may not be necessary
to reduce drug trafficking. Presumably
that intervention has been constant over the course of the recorded data and it
has had minimal impact. It is also high risk and places certain demographic
groups at higher risk. Second, this may
be a transient effect. Drug traffickers
can adapt as noted by the difference in how fentanyl makes it to the streets in
the US compared to Canada. Finally, if
this was in fact the effect of diplomacy those efforts should be increased
rather than decreased. India is a source of precursors and in some cases direct
to consumer shipments of controlled substances.
Diplomatic efforts could yield further disruptions in the supply chain
and less problems with opioids on the streets of the US.
There is now a fourth
implication and that is that gunboat diplomacy and the questionable use of the
US military against boats suspected of carrying drugs is unnecessary. It also highlights that the Executive order
to declare war on cartels was also unnecessary.
There was a substantial drop in overdose deaths before any of these
measures was employed and it may be an indication that diplomacy is the way forward.
If I was a conspiracy theorist, I would
suggest that Trump wants to get credit for the drop in fentanyl trafficking
that occurred in the Biden administration.
According to the authors of this paper we do not know if this is a
long-term trend or not. Since most fentanyl trafficking does not originate in
Venezuela or the countries surrounding the targeted areas it is unlikely to
have a big effect.
That 30% decrease in
mortality cannot be ignored and a closer examination of the Biden negotiations
is warranted.
George Dawson, MD, DFAPA
References:
1: Watson B, Peniston
B. The D Brief: ‘Perfidy’ in boat
strike?; Pentagon’s new AI plan; Venezuela’s broken air defenses; Quantum space
cameras; And a bit more. Defense
One. January 13, 2026. https://www.defenseone.com/threats/2026/01/the-d-brief-january-13-2026/410643/
2: Tait R. Killing of
survivors sparks outrage – but entire US ‘drug boat’ war is legally shaky. The Guardian.
December 4, 2025. https://www.theguardian.com/us-news/2025/dec/04/venezuela-boat-strikes-legality-hegseth
3: Vangelov
K, Humphreys K, Caulkins JP, Pollack H, Pardo B, Reuter P. Did
the illicit fentanyl trade experience a supply shock? Science. 2026 Jan
8;391(6781):134-136. doi: 10.1126/science.aea6130. Epub 2026 Jan 8. PMID: 41505547.
Graphics:
1: Lead graphic is
from the CDC and is in the public domain: https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html
2: The graph of fatal
overdose deaths per year shows the number of fatal opioid overdose deaths in
the United States from 2000 to 2025. The
data from 2000 to 2023 consists of final and reported figures from the Centers
for Disease Control and Prevention (CDC) and the National Institute on Drug
Abuse (NIDA). The figures for 2024 and 2025 are based on provisional counts and
projections released by the CDC's National Center for Health Statistics (NCHS)
as of January 2026.
3: Graphics 2 and 3 were designed with the assistance of Google Gemini.
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