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The FUTURE of FENTANYL and OTHER SYNTHETIC OPIOIDS C O R P O R A T I O N The FUTURE OF FENTANYL and OTHER SYNTHETIC OPIOIDS Bryce Pardo, Jirka Taylor, Jonathan P. Caulkins, Beau Kilmer, Peter Reuter, Bradley D. Stein For more information on this publication, visit www.rand.org/t/RR3117 Library of Congress Cataloging-in-Publication Data is available for this publication. ISBN: 978-1-9774-0338-4 Published by the RAND Corporation, Santa Monica, Calif. © Copyright 2019 RAND Corporation R® is a registered trademark. Cover: Fentanyl molecule structure/serge01/Adobe Stock. Limited Print and Electronic Distribution Rights This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial use. For information on reprint and linking permissions, please visit www.rand.org/pubs/permissions. The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. Support RAND Make a tax-deductible charitable contribution at www.rand.org/giving/contribute www.rand.org This report is dedicated to Mark A. R. Kleiman, our friend, col- league, and inspiration. As this analysis describes, the fentanyl problem is unlike any preceding drug epidemic in fundamental and challenging ways. Likewise, Mark was unlike any other who labored in the field of drug policy. He was a one-of-a-kind thinker who challenged status quo beliefs by grappling with the fundamen- tal behaviors of people and markets—always with the determina- tion to make the world a better place, just as he has made each of us better scholars and better people through his wise mentoring. Mark will be long remembered by the field and missed by us all. Mark A. R. Kleiman 1951–2019 iii Preface The U.S. opioid crisis worsened dramatically with the arrival of syn- thetic opioids, such as fentanyl, which are now responsible for tens of thousands of deaths annually. This crisis is far-reaching and even with prompt, targeted responses, many of the problems will persist for decades to come. RAND Corporation researchers have completed numerous opioid-related projects and have more underway for such clients and grantors as the Agency for Healthcare Research and Qual- ity, the Assistant Secretary of Health and Human Services for Plan- ning and Evaluation, the National Institute on Drug Abuse, the White House Office of National Drug Control Policy, and Pew Charitable Trusts. Researchers have advanced an understanding of the dimen- sions of the problem, some of the causes and consequences, and the effectiveness of different responses. However, no one has yet addressed the full scope of the problems associated with opioid use disorder and overdose deaths. Beginning in late 2018, the RAND Corporation initiated a com- prehensive effort to understand the problem and responses to help reverse the tide of the opioid crisis. The project involves dozens of RAND experts in a variety of areas, including drug policy, substance use treatment, health care, public health, criminal justice, child welfare and other social services, education, and employment. In this work, we intend to describe the entire opioid ecosystem, identifying the compo- nents of the system and how they interact; establish concepts of success and metrics to gauge progress; and construct a simulation model of large parts of the ecosystem to permit an evaluation of the full effects v vi The Future of Fentanyl and Other Synthetic Opioids of policy responses. We dedicated project resources and communica- tions expertise to ensure that our products and dissemination activities are optimized for reaching our primary intended audiences: policy- makers and other critical decisionmakers and influencers, including those in the public, private, and nonprofit sectors. The project is ambi- tious in scope and will not be the last word on the subject, but by tack- ling the crisis in a comprehensive fashion, it promises to offer a unique and broad perspective in terms of the way the nation understands and responds to this urgent national problem. Ten years ago, few would have predicted that illicitly manu- factured synthetic opioids from overseas would sweep through parts of Appalachia, New England, and the Midwest. As drug markets are flooded by fentanyl and other synthetic opioids, policymakers, researchers, and the public are trying to understand what to make of it and how to respond. The synthesis of heroin in the late 19th century displaced morphine and forever changed the opiate landscape, and we might again be standing at the precipice of a new era. Cheap, acces- sible, and mass-produced synthetic opioids could very well displace heroin, generating important and hard-to-predict consequences. As part of RAND’s project to stem the tide of the opioid crisis, this mixed-methods report offers a systematic assessment of the past, present, and possible futures of fentanyl and other synthetic opioids found in illicit drug markets in the United States. This research is rooted in secondary data analysis, literature and document reviews, international case studies, and key informant interviews. Our goal is to provide local, state, and national decisionmakers who are con- cerned about rising overdose trends with insights that might improve their understanding of and responses to this problem. We also hope to provide new information to other researchers, media sources, and the public, who are contributing to these critical policy discussions. RAND Ventures The RAND Corporation is a research organization that develops solu- tions to public policy challenges to help make communities through- Preface vii out the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RAND Ventures is a vehicle for investing in policy solutions. Philanthropic contributions support our ability to take the long view, tackle tough and often-controversial topics, and share our findings in innovative and compelling ways. RAND’s research findings and recommendations are based on data and evidence, and therefore do not necessarily reflect the policy preferences or interests of its clients, donors, or supporters. Funding for this venture was provided by gifts from RAND sup- porters and income from operations. Contents Preface .............................................................................. v Figures ............................................................................. xi Tables .............................................................................xiii Summary ..........................................................................xv Acknowledgments .............................................................xxix Abbreviations .................................................................. xxxi CHAPTER ONE Introduction ....................................................................... 1 Objectives of This Report ......................................................... 3 Mixed-Methods Approach ........................................................ 5 Structure of This Report .......................................................... 7 CHAPTER TWO Insights From Mortality and Seizure Data in the United States ......... 9 Drug Overdose Fatalities .........................................................10 Supply-Side Indicators ........................................................... 23 Pairing Laboratory Seizure Data with Fatal Synthetic Opioid Overdose Data ............................................................................39 Summary of the Situation in the United States .............................. 42 CHAPTER THREE Assessing Explanations for the Recent Rise in Synthetic Opioids ......45 Fentanyl: Dealer’s Choice? ...................................................... 46 Previous Outbreaks and the Clandestine Production of Synthetic Opioids ....49 The Current Outbreak ...........................................................53 ix x The Future of Fentanyl and Other Synthetic Opioids Factors That Contribute to the Rise of Fentanyl and Other Synthetic Opioids Today ............................................................... 56 The Rise of Fentanyl ..............................................................71 CHAPTER FOUR International Experiences with Synthetic Opioids ........................73 Selection of Focus Countries ....................................................74 Country Profiles ...................................................................76 Summary of Market Characteristics and Variations Across Countries ... 102 Factors Associated with the Emergence of Fentanyl ........................ 107 Themes Emerging from Existing Fentanyl Markets ........................ 111 Reflections on Lessons for the United States from Other Countries ..... 116 CHAPTER FIVE Some Possible Futures for Fentanyl and Other Synthetic Opioids ... 119 Scenario 1: Flash and Recede .................................................. 120 Scenario 2:
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