The DEA just published a significant report on the drug
threat in the United States. I read the entire document and will review a few
of the high spots here highlighting why it is not too relevant for most parts
of the country. I am on record in
several places on this blog making similar comments. My basic argument has not
changed significantly and that is that the demand for illegal and often fatal
drugs is driven by the culture in the US and I would not expect law enforcement
to make much of a difference. The case in point is Prohibition and the ban on
alcohol. Of course it was not a real
ban. Criminals still bootlegged alcohol
into the country, religious groups found a way to circumvent the law, and there
are always people producing illegal alcohol as a significant percentage of
alcohol consumed every year.
These facts are most often distorted into the argument that
Prohibition or any War on Drugs is doomed from the outset. That argument
is most frequently used to implicitly suggest that any attempt to legally
restrict intoxicants will be righteously overcome by people with a natural right
to pursue intoxication. That is
extrapolated to practically any scenario short of negligent homicide due to
intoxication or drug dealing. But even the drug dealing scenarios are being
rapidly modified to allow possession of certain amount of cannabis or in some
cases legitimizing drug dealing as a useful occupation. The direct and indirect
costs of drug use to both individuals and society are typically ignored by
anyone without a medical or public health interest. Intoxication is a cultural
right, a right of passage, and every effort of being made to expand the
availability of intoxicants to everyone in the US.
The DEA (1) states their role is to expand awareness,
preserves lives, and provide intelligence to law enforcement that might be
useful for resource allocation and prioritization. Synthetic
opioids and stimulants are described as the biggest threats. Both can be easily mass-produced by the
cartels in Mexico. Fentanyl alone has
accounted for a massive increase in mortality due to its potency and low
therapeutic index – accounting for 74,225 deaths in 2022. China is implicated as the main source of
precursor drugs to produce fentanyl.
The report clearly states that two Mexican cartels are
responsible for the drug flow into the US and the most significant drug crisis
in the history of the US. Further – the
cartels have penetrated most states in the US to varying degrees. The Internet has facilitated drug sales in
the US and made these transactions more difficult to track. The cartels are also producing methamphetamine
leading to an increase in stimulant associated deaths. There is also a China connection. Chinese criminal operations supply precursors
for the synthesis of opioids and methamphetamine as well as money laundering
operations to make the money from illegal drugs sales useable.
One of the strategies these criminal enterprises are using
is adding additional intoxicants to the drug that users are purchasing. This has the effect enhancing the intoxicating
effects but with a much higher risk of overdose and death – especially if the user is
naïve to that drug or the seller is ignorant about the potency of the
additional intoxicant. I became aware of
this phenomenon about a decade ago when I was being told that users witnessed
fentanyl being pressed into alprazolam tablets and sold as alprazolam. A secondary phenomenon was that many people
were not averse to fentanyl but actively sought it out to enhance the period of
intoxication. The DEA report describes
the following combinations:
|
Fentanyl
plus: |
|
Heroin,
cocaine, methamphetamine, xylazine, Counterfeit
prescription drugs: (oxycodone (M30, Percocet); hydrocodone (Vicodin); or
alprazolam (Xanax) |
The DEA report addresses many of the logistics of the
substance use problem and it does raise awareness – especially of the dangers
of getting adulterated drugs and the severe side effects including death. It
also highlights drug counterfeiting and it gives a great example of an Adderall
tablet counterfeited from methamphetamine (see below). That
is especially problematic during a time of Adderall shortages from legitimate
suppliers.
The unaddressed problem is American culture. I don’t want to suggest that large groups of sociopaths intent on making money no matter how many people they kill don’t bear some responsibility. I also don’t want to suggest that reducing the availability of these drugs by any means is not a good idea. But one of the takeaways from reading this report is that law enforcement is clearly not winning and it is a huge burden on them in both the US and Mexico. Former President of Mexico Vincente Fox characterized the problem well as “America’s insatiable appetite for drugs.” Right now, it is a multigenerational chronic problem. People can get effective treatment and recover but too many die and too many become chronic users. There needs to be an effective strategy for primary prevention or preventing use in the first place. Suggestions along these lines typically end up caricatured as the 1980s “just say no” public service ads or the "failed war on drugs", but this strategy was clearly effective in reducing cigarette consumption and decreasing the population of smokers. It has had the expected effects of decreasing smoking related mortality in both the general population and in smokers who quit. The same population-wide benefits would be expected from any public health measure that effectively reduced the use of alcohol, stimulants, opioids, cannabis, or any other intoxicants. What are the cultural factors that keep this drug epidemic going? Here are a few:
1: Cultural
acceptance of substance use as a rite of passage: The stories are endless. Fraternity and sorority
hazing involving excessive alcohol use.
High school graduation parties associated with multiple driving while intoxicated
deaths. Incarceration from assaults and homicides from barroom fights. Consumption
of alcohol and other intoxicants in high school well before the legal age for
consumption has been reached. Much of this has to do with immaturity. The Decade
of the Brain did inform us that just on a biological basis human brains do not
mature until the mid 20s and in the case of men possibly even later. Immersing
an immature brain in intoxicants is generally not a recipe for success and may
be a developmental risk for substance use disorders and mental illnesses.
2: Consumerism and
the selling of intoxicants: This is a
widespread phenomenon in the US. Alcohol
commercials typically suggest success, sexual attractiveness, popularity,
sophistication, and glamour.
Identification with Hollywood A-listers is a plus and many of them are marketing
their own brands to capitalize on that fact. The expensive packaging is often
more significant than any difference in taste or quality. The only downsides
are a very brief allusion to the Surgeon General’s warning about alcohol use in
pregnancy or a disclaimer to “use responsibly.”
Not much about alcohol poisoning, cancer, cirrhosis, pancreatitis, cardiac problems, dementia risk, or substance induced psychiatric disorders. For a long time alcohol was hyped as a heart health beverage.
3: Your right to intoxicants: The subculture of users has a mixed agenda in
promoting this idea. There are a few
people who believe that their lives are better by using drugs or alcohol, that
they are using these substances in a controlled manner and “not hurting anybody.”
And therefore, anyone should have the right to use them under these conditions. On the face of it – few people would argue
that point – even though it does assume that self-report about use and
its consequences are always accurate. A subgroup
is promoting widespread intoxicant use as a business. Many in this group see it as a get rich quick
scheme. Many see it as a diversity equity inclusion (DEI) issue. That is – minority groups sustained harm from excessive legal penalties against cannabis and other drug possession and therefore they should be given advantages in setting up businesses that profit from legalization. Many
want to extend cannabis law changes to include all drugs and legalize access to
everything. The DEA report stands in contrast to mass legalization because it
estimates how much the country would be awash in fentanyl if it was legal. It also
ignores why substances were controlled in the first place and what happened
when physicians started to prescribe more opioids both as "dope doctors" in the early 20th century maintaining people in addiction and in the late 1990s leading to
the beginning of the current opioid epidemic.
4: Cannabis
misinformation: There has not been much
reflection of the medical cannabis period of the early 21st
century. Cannabis was touted as a miracle
drug whose benefit was being neglected due to archaic drug laws and the lack of
modern research. Nothing was said about cannabis being around for over 700
years and having no clear cut indications for use or the fact that earlier cannabis compounds fell into disuse with modern therapeutics. That led to a patchwork of state-level medical cannabis laws, making each of those states a Mini-FDA with their own
indications for use and in some cases limited forms of cannabis that could be
dispensed for those indications. Just as
it became apparent that cannabis really was not much good for medical
applications or even pain – the real motivation for the medical cannabis Trojan
Horse became apparent. That was of
course recreational use. The Biden administration is currently considering rescheduling
cannabis from a Schedule I to a Schedule III substance. That takes it off the experimental/no
medical application category but still suggests that it will be prescribed and
supervised by a physician.
5: Widespread promotion
of hallucinogens and psychedelics as miracle drugs: Building on the success of promoting
cannabis as a medicine – we are now seeing frequent hype about the wonderful
effects of psychedelics along with practically no discussion of the side
effects. MDMA and LSD are being seen as wonder drugs that successfully treat depression,
anxiety, PTSD, and substance use disorders. The cannabis promoters successfully
promoted cannabis as a nearly completely benign substance and the hallucinogen/psychedelic
promoters have used the same tactic. I
only recently read an account where the following side effects during a clinical
trial of an LSD based drug were listed: illusion, nausea, euphoric mood,
headache, visual hallucination, mydriasis, altered state of consciousness,
anxiety, blood pressure increase, and abnormal thinking (all in significant
numbers). In my clinical experience I have treated people with permanent side
effects from this drug class after a single dose.
6: Better living
through chemistry: There is a current
wave of euphoria in the popular culture about GLP-1 agonists like Ozempic and
Monjauro. It has been accompanied by FDA approved indications but also a very
public reexamination of the usual prescriptions of diet and exercise for weight
loss. The pendulum seems to have swung to the point that all excessive weight is
a disease state that can only be approached with a powerful drug that has
potentially powerful side effects. From
a cultural perspective this class of drugs reinforces the American
dream that we can tune our bodies like we tune our cars and if we have the
right drugs – we can have whatever kind of body or mind that we want. More longstanding evidence of this attitude is evident from anabolic androgenic steroid use and stimulant use for - both for performance enhancement. All three are grand illusions. Hominid biology has evolved to incredible
complexity over the past 2 millions years.
Any group of people may look alike but there are hidden differences in
physiology and pharmacological response. One person’s medication is another person’s
poison. As a result there are very few miracle drugs and some intoxicants have been
around for centuries making it even less likely.
7: Sobriety as a
subculture: In most societies certain religions
and life philosophies are the most likely promoters of sobriety. Most
sobriety in the US is not thought about too much. There are about 60% of people who never
drink. There is a group of people in active recovery who had a problem with
intoxicants and were successful in discontinuing them. There is a small movement right now of young
people who are not in recovery promoting sobriety. The cultural resistance against substance use
in the US seems trivial compared with the promotions.
8: Treatment is secondary prevention: A standard political approach to the drug epidemic these days is to suggest that more availability of treatment centers and providers is a needed approach. This is correct in so far as treatment for these conditions has always been deficient. Treatment has had a role in terminating localized drug epidemics in both Chicago and Washington DC. There is a question about how well it will work now that just about every county in the US is awash with opioids and methamphetamine. A logical approach may be to prevent new users from entering this cycle – in other words decreasing the incidence of the problem. Unfortunately there are fewer resources to address this problem and a lot of pessimism about that approach.
9: Intoxicant use is a choice: Even though there is obvious
evidence out there that a significant percentage of the population develops
uncontrolled use of drugs and/or alcohol denial and rationalizations about this
continues to persist. It has to in order to maintain the myth that people with
substance abuse disorders really have a moral defect rather than a biological
propensity. In other words – repeatedly telling
them to stop and blaming them for the problem is all that is required. That
approach ignores the real problem that if you are biologically disposed – all it
takes is access to substances to keep that process going. The moral approach
also allows for a legalization position by simply stating that the people who
cannot control their use are irresponsible.
10: Deaths of
despair: This concept was popularized by Dean and Case (2) to explain
increased mortality due to intentional injury and drug overdoses caused by
hopelessness due to economic problems and the associated stress. Deaths due to
alcohol and drug use were seen because of economic stress rather than a consequence
of excessive use for other reasons including the cultural factors that have
been specified. The concept minimizes the fact that severe alcohol and drug
problems exist in populations that have no economic stress and that most of the
people with severe economic stress do not have drug and alcohol problems. It
also minimizes the fact that we are still in the midst of a multi-decade
drug epidemic and there is no end in sight.
11: Legalizing drugs will put the cartels out of business: This has always been an extremely naïve argument. Alcohol and tobacco sales are legal and taxed but that does not prevent their illegal sales. Prescribing opioids, stimulants, and benzodiazepines does not prevent their illegal sales. The DEA report highlights continued involvement by organized crime in cannabis production and sales - even after it has been legalized. Illegal production has led to violent crime and adverse environmental impact. These same organizations are currently producing counterfeit name brand pharmaceuticals. There is no reason to expect that legalizing very high risk drugs will stop criminals from producing or selling them.
12: No education about who may be at higher risk: To an addiction psychiatrist seeing people after acute events the risks are obvious. People who use intoxicants and get extremely euphoric or aggressive to the point that it impairs their judgment are clearly at high risk and should consider not using them at all. Unfortunately that self examination often does not happen until there has been a life changing event. People with a strong family history of substance related problems are another high risk group. Some individuals come to the conclusion that intoxicants are too risky for them to use. I have heard this in many psychiatric evaluations: "My father and his father were alcoholics. I knew I should probably not drink on that basis." But this knowledge does not seem to be widely disseminated.
Where does all of this leave us? Not in a very good place. The DEA is
describing its efforts to intercede in what is a massive effort originating from several
countries to import highly dangerous substances into the United States.
Although it is never overtly discussed this is clearly a national security
problem. The immediate problems of deaths and morbidity from drug addiction
seem to depend very little on how successful the DEA is in its efforts. The
reason for that is the massive promotion of drugs at the cultural level both in
direct advertising and false political philosophy equating drug use with
freedom. It parallels the use of the Second Amendment to promote the widespread
dissemination of firearms – even though there is no similar amendment for drug
use. All the popular myths about drug use need to be actively countered and the
advantages of a sober life need to be promoted. Those myths are a more subtle
but equally dangerous threat to what the DEA is describing in this report.
George Dawson, MD, DFAPA
References:
1: Drug Enforcement
Administration. National Drug Threat Assessment. US Department of Justice. May 2024.
57p.
2: Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015 Dec 8;112(49):15078-83. doi: 10.1073/pnas.1518393112. Epub 2015 Nov 2. PMID: 26575631; PMCID: PMC4679063
