Isotonitazene. Xylazine. Etizolam. These drugs sound like they belong in a dystopian sci-fi film. So does the manufactured plague of which they’re a part.
Although few people have heard of these synthetic compounds, they’ve catapulted the United States’ overdose crisis to global distinction. With nearly 108,000 deaths from overdose in 2021, the US now has an overdose mortality rate that’s about 20 times the worldwide average and more than double that of the next closest nation.
But to understand—and to stop—the waves of drug-related deaths, we have to start with a widely misunderstood family of drugs: fentanyls.
The public has been bombarded with misleading media coverage about fentanyls—a group of synthetic opioids produced in clandestine labs that has been replacing heroin in the North American drug market over the past decade. Fentanyls are typically many times more powerful than plant-based heroin, but their potency fluctuates depending upon producer and batch. From day to day, drugs in the same area have been shown to contain anywhere from 1 percent to 70 percent fentanyl, a range that would be unthinkable for a product subject to quality regulations. It’s this variability that has ushered in the deadliest overdose epidemic in human history.
But fentanyls are just the beginning.
We are now in the so-called fourth wave of the overdose crisis. Underground labs are pumping out an evolving plethora of novel synthetic compounds. These synthetics are added to fentanyl-based street drugs in pursuit of newfound highs and more addictive properties. These ever-shifting chemical formulations leave consumers with little knowledge of what’s in the drugs they’re using.
One popular product in this line, for example, is “tranq dope.” It first emerged in Puerto Rico, then spread to Philadelphia, and is now becoming prevalent all over the United States. Tranq dope is fentanyl mixed with xylazine, a veterinary tranquilizer that’s never been approved for human use. Although systematic study has been made difficult by the underground nature of production and use, this combination has been linked to dangerous blackouts, severe skin and soft tissue damage, and unusual blood disorders.
Another street formulation, “benzo dope,” mixes fentanyls with synthetic benzodiazepines. Benzo dope is now popping up in the US after already becoming pervasive in Canada and Scotland, where a single one of these benzodiazepine additives, Etizolam, was involved in 59 percent of all drug-related deaths in 2019. Benzo dope is associated with significantly increased risk of fatal overdose by sedating people while suppressing their respiratory drive, slowly suffocating them until their heart stops beating.
These dangerous drugs are just the tip of the iceberg. Between newly synthesized stimulants, cannabinoids, opioids, benzodiazepines, tranquilizers, and other compounds, thousands of new drug combinations are sold as prepackaged products on US streets every day. And while these products kill at an increasing rate, US drug policy has left those charged with preventing and treating these overdoses—from public health officials and scientists to emergency-room doctors—almost completely in the dark about what they’re facing.
A Deadly Knowledge Gap
The true magnitude of the synthetic drug wave is largely unknown. Underfunded medical examiners are running test after test on the corpses piling up in morgues, in a scramble to keep up with the rapidly shifting profile of street drugs. No one knows the range of drugs responsible for the deaths we are witnessing.
This lack of knowledge is a major factor behind America’s worsening overdose crisis.
When faced with poorly understood threats, there is an entrenched commitment to the belief that police and prisons can make us safe. Throughout US history, fear of the unknown has been met with repression and punishment. Predictably, that now includes calls to increase criminal charges for possession of fentanyl and other synthetics. The US government continues to fight its “war on drugs”—squandering many billions of dollars annually, locking up millions of people, and paying foreign militaries to destabilize foreign drug traffickers. The failure of this war became clear decades ago, but it is still devastating US communities.
What’s known as the Iron Law of Prohibition helps explain why. For over a century, observers have noted that when police and militaries clamp down on illicit drug supply chains, it promotes the sale of increasingly dangerous drug formulations.
This was seen with alcohol prohibition in the 1920s, for example. As breweries were shut down, beer and wine were replaced by more potent grain alcohol produced in underground, makeshift distilleries. Toxic methanol soon proliferated, and overdoses and deaths followed.
America’s overdose disaster today reflects the effects of the Iron Law after disruption to supply chains for prescription opioids and agricultural heroin. The market has adjusted to restrictions, which have ultimately benefited traffickers. Instead of transporting a truck full of heroin as in years past, today it takes only a packet of fentanyl—easy to conceal in a small car—to achieve the same effect and generate similar profits, as fentanyl analogues can be thousands of times more potent than heroin by weight.
US lawmakers have taken the logic of policing drugs to its extreme and found out what it yields: mass incarceration and mass death. No country has spent more money on interdicting substances, surveilling and incarcerating people, and punishing those who use drugs than the United States, and no other nation has seen its communities as decimated by overdose.
Ensuring Safe Supply
A half-century since President Richard Nixon announced America’s war on drugs, illicit substances remain inexpensive, readily available, and deadlier than ever.
In a country with as much poverty and inequality as our own, the illicit drug market bears out a classic economic rule: Where there is demand, there will be supply. This market is a hydra. Each time one drug becomes the focus of elimination efforts, a new one—typically even more deadly and more profitable—rises in its place.
If US policy-makers are going to stop the accelerating rate of overdose deaths, then they must embrace a paradigm shift in public safety. We must reorient policy away from the fantastical promises to eliminate drugs and instead invest in harm reduction—that is, the task of making drug use as safe as possible while providing focused support for richer life opportunities to those at greatest risk of harm from drugs.
Rather than spend endless public dollars trying to interrupt the supply of drugs, we should focus on empowering consumers to select safer products and avoid overdose. A key strategy for this lies in making drug-checking resources available to consumers.
Technology now exists that can allow consumers to learn almost immediately what’s contained in the products they’ve acquired.
At drug-checking sites housed in harm-reduction community centers, for example, people bring a drug sample for testing without fear of police surveillance or retribution, and can walk away 10 minutes later with a full ingredient list. The read-out informs them not just of what compounds are present in their drugs, which allows people to confirm whether they have in fact been sold what they intended to buy, but also shows them the concentration and risk of each ingredient.
Similar to how nutritional labels at grocery stores and restaurants provide information regarding the sugar, saturated fat, and calorie content of packaged goods in order to help consumers make healthier choices, drug-checking services allow consumers to make informed decisions as they seek to balance their desire for a high with concerns about their safety. When people can know what it is they’re really buying, this produces market feedback that pushes producers to make safer products that reduce risk on a population level. In short, drug checking allows us to flip the script on the market dynamics driving the overdose crisis by leveraging market feedback to the benefit—rather than detriment—of public safety.
The knowledge that drug-checking provides is essential not only for facilitating safe drug use at the individual level but also for allowing public health officials to monitor the supply for emerging threats and to act on this knowledge to protect the public. If, for example, a particularly dangerous synthetic analogue is synthesized and added to the street market, consumer-oriented drug-checking systems give us the capacity to detect it early. This would allow officials to spread the word among consumers, first responders, and community groups instead of waiting for a rash of overdoses to prompt toxicology testing while preventable deaths accumulate.
With current technology, drug-checking centers are affordable to equip and maintain, but, like so many of the harm-reduction services that data very clearly shows work far better than policing to improve safety, they need public backing to be implemented and trusted. They won’t work, for example, if police are allowed to try to use them as means of identifying, tracking, and punishing consumers.
Another key approach backed by decades of evidence is safe supply—that is, giving people struggling with addiction something safer to use instead of forcing them to rely on toxic street drugs. Many people currently at the highest risk of overdose from synthetic drug combinations would return to pharmaceutical opioids if given a supply. Decades of studies have shown that meeting people where they are at with respect to drug use and providing options to use more safely is far more effective than trying to shame or strong-arm people into abstinence. That means prescriptions for methadone or, for those for whom methadone is not sufficient, for quality-controlled heroin itself, as has been standard practice in several European nations for many years.
There are different models for ensuring safe supply, some with direct medical provision and others that rely on community organizations. The details can be debated, but the overall evidence is clear: It is the toxic drug supply that is killing people, and while it cannot be eliminated, it can be replaced with something far safer. Investments in safe supply would improve public health and safety and dramatically reduce overdose risk.
The Roots of Addiction
In addition to ensuring safe supply, to end the overdose crisis, lawmakers need to invest in even more obvious, basic safety policy: giving vulnerable people the economic support and health care required to stabilize their lives.
Millions of Americans have suffered substantial life traumas and have never had access to proper care or stable life conditions that would allow them a chance to address these experiences. In the absence of such support, drug use is an extremely common means by which many attempt to cope with trauma, isolation, and economic precarity. Victims of overdose disproportionately come from the most dispossessed communities in our deeply unequal society. They are, for example, much more likely to have experienced violence, abuse, hunger, and the incarceration or death of family members during childhood.
Many people who live with addiction report that illicit drugs are the only thing that has kept them alive through cycles of pain, loss, and abuse. And once someone is struggling with addiction, the US health care and housing systems have made it extremely difficult and costly to find an exit. In our for-profit health care landscape, clinics often charge nearly $1,000 per month in out-of-pocket fees for buprenorphine treatment, an evidence-based medication that helps reduce cravings for opioids. Many who can’t afford such health care expenses in our dysfunctional medical system continue to be tumbled through cycles of incarceration, poverty, and desperation.
Evidence has shown time and time again that stable housing, emergency financial assistance, mental health services, continuous health care access, and substance-use treatment alongside community support systems are extremely effective means of reducing overdose risk and improving community safety for everyone. There is no lack of data to support public policies to provide these services. What we are suffering from is a lack of courage among politicians who remain captive to the war on drugs, regardless of the thousands of lives it continues to destroy with each passing month.
The synthetic plague is here. And the reality is that it’s not going anywhere until our elected representatives shake free of the delusion that prohibition keeps communities safe.