Fentanyl, a synthetic opioid, was first synthesised in 1959. Like its naturally occurring opioid counterparts, morphine and codeine, it was introduced for pharmaceutical purposes as a potent and effective treatment for severe or long-term pain, and used as an intravenous anaesthetic.
But since then, that legacy has taken a dark turn. Originally intended to relieve people from medical distress, the highly addictive and potent drug has become subject to abuse, leading to a significant increase in fentanyl-related overdose deaths. The crisis is most prominent in the United States, which is currently in the grip of a deadly opioid epidemic.
There, drug overdose deaths more than doubled between 2013 and 2021, a year in which roughly 70,000 of the total 106,699 drug overdose deaths involved synthetic opioids. Driving this surge is illicitly manufactured “street” fentanyl, the opioid most involved with American drug deaths. Fentanyl is incredibly powerful – up to 50 times stronger than heroin and 100 times stronger than morphine. Because it is cheap to produce, it is often cut into other drugs. Both these characteristics make it perilously easy for users to overdose.
The situation has caused alarm among American policymakers, who have declared a public health emergency. Alejandro N Mayorkas, the homeland security secretary, has branded fentanyl overdoses “one of the greatest challenges that we are facing as a country”. It is estimated the soaring drug death rate costs American society $1.5trn each year.
By contrast, the UK has so far mercifully avoided the worst of the opioid crisis. In 2021, England and Wales reported 58 deaths in which fentanyl featured on the death certificate, a death rate of less than 0.1 per 100,000 people. All premature loss of life is tragic, but that is a drop in the ocean when compared with the number of fentanyl-related deaths in the US, which was 200 per day in 2022.
But this might be deceptive, a calm before the storm. Experts are already raising the possibility that the UK could suffer its own opioid epidemic. Nearly half of all drug poisonings in England and Wales involved opiates (naturally derived opioids) in 2021, while opioids and opiates are the predominant cause of drug misuse deaths in Scotland, implicated in 82 per cent of all deaths.
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Britain is vulnerable to the introduction of powerful novel opioids, with new products entering the market all the time – some recently containing fentanyl. Another group of powerful synthetic opioids, nitazene, has been detected across all four UK nations.
Global supply dynamics may also contribute to this potential crisis scenario. The recent Taliban ban of opium production in Afghanistan, the world’s leading exporter of the substance, could create a vacuum in the UK, which is used to sourcing 95 per cent of its heroin from Afghanistan. If that supply dries up, dealers may well turn to more dangerous products such as fentanyl and nitazene.
UK policymakers must proactively confront this perfect storm before the domestic situation deteriorates further.
The radical approach would be to overhaul drug legislation. In Portugal, decriminalisation and the shift to a public health framework has led to positive outcomes for vulnerable users, including a dramatic reduction in drug deaths. The Home Affairs Committee recently endorsed a greater emphasis on public health and called for reform of the Misuse of Drugs Act, though it did not go as far as to call for decriminalisation. Some caution is justified: poorly implemented liberalisation could lead to increased availability and consumption. With drugs as deadly as fentanyl, this could have disastrous consequences.
Within the prevailing system, a potential avenue might be to crack down on the illegal black market. In Estonia in 2017, authorities successfully cut off fentanyl supplies, also resulting in a drop in overdose fatalities (though users did turn to other synthetic drugs, including alternative opioids). This approach might bring short-term relief, although some worry about the long-term effect of perpetuating the contentious “war on drugs” and the criminalisation of users. The lesson from tackling other substances shows that prohibition does little to support those who are vulnerable.
We should be looking to support evidence-based public health initiatives. In the US, a nation in need of fast action, small-scale interventions like syringe services, fentanyl test strip distribution and a drug overdose health alert network are being employed in response to the rampant opioid crisis.
With signs showing that the UK may be headed in a similar direction, campaigners are urging the government to act. A recent report from the social justice charity, Cranstoun, has outlined an eight-point plan for addressing the potential crisis. It includes targeted proposals such as expanding the distribution of Naloxone (an opioid overdose reversal drug), increasing access to substitution treatment and establishing overdose prevention centres.
Such a programme requires funding. Given the astronomical human and economic costs of a US-style crisis, it would be a worthwhile investment. The American experience shows that no price is too high for supporting harm reduction at the earliest opportunity.
Predicting the trajectory of the illegal drugs market is difficult, and we can hope that potent substances such as fentanyl and nitazene fail to penetrate the UK. But in case they do, we need to be prepared – we need to stay ahead of the curve by implementing the necessary harm-reduction policies. Thousands of lives may depend on it.
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