Drug Overdose Deaths in America - Another Unintended Consequence of Government's Response to the Pandemic

In its most recent data release, the Centers for Disease Control and Prevention outlines one of the most serious health issues facing the United States, an issue which has worsened significantly since the onset of the COVID-19 pandemic one year ago.  While I have posted on this subject in the past few months, it is important for us to understand how government's response to the pandemic continues to have a negative and far-reaching impact on certain subgroups of Americans.

  

Here is a graph showing the 12 month-ending provisional number of drug over deaths for the entire United States with the circles showing the predicted number of drug overdose deaths and the solid line showing the actual number of overdose deaths:

 

In the 12 month period ending in September 2020, the last month for which data is available, there were 87,203 drug overdose deaths, up from 68,757 in the year prior to September 2019 (i.e September 2018 to September 2020), an increase of 26.8 percent.

  

Here is a graphic showing the 12-month-ending provisional number of drug overdose deaths by drug type or drug class:

 

By drug type or drug class, the month-ending provisional number of drug overdose deaths were as follows 

 

1.) Opioids - 64,472

 

2.) Synthetic Opioids excluding methadone - 53,877

 

3.) Psychostimulants with abuse potential - 21,961

 

4.) Cocaine - 19,239

 

5.) Heroin - 13,780

 

6.) Natural and semi-synthetic opioids - 13,122

 

7.) Methadone - 3,361

  

In comparison, in September 2019, the 12-month-ending provisional number of drug overdoses from opioids was 48,140 and from synthetic opioids was 34,057. 

 

Here is a graphic showing the predicted percent change in drug overdose deaths between September 2019 and September 2020:

 

Here is a table showing the 9 states with the most drug overdose deaths:

 

Here is a table showing the 10 states with the least drug overdose deaths:

 

Here is a table showing the 10 states with the greatest percentage increase in drug overdose deaths:

 

Here is a table showing the 10 states with the lowest percentage increase in drug overdose deaths:

 

 

It is quite clear that the pandemic has had a significant and ongoing impact on the number of drug overdose deaths in the United States, thanks in large part to the government-ordered closures of treatment programs, drop-in centers that provide safe injection sites and naloxone.  For example, a 2020 study by Sara Glick et al found that 43 percent of Syringe Services Programs (SSP) reported a decrease in the availability of services due to COVID-19 including 25 percent that reported that one or more of their sites had closed due to the pandemic.  

  

Let's close this posting with the conclusion from Glick's analysis which clearly outlines the issue:

  

"While SSPs are to be admired for their resiliency and ingenuity in the present COVID-19 pandemic situation, the problems presently facing SSPs must not be underestimated. Clients are likely to have great difficulty social distancing and “staying at home;” most will need to obtain drugs to avoid withdrawal and many remain homeless. Many SSPs have closed and those that remain open have greatly reduced their services, are struggling to procure sufficient PPE for staff, and have been forced to reduce testing for blood borne pathogens, a change that could lead to increasing rates of HIV and HCV among an already vulnerable population."

  

The rising number of drug overdose deaths in the United States over the past year is yet another  in a long line of unintended consequence of the governments' response to the COVID-19 pandemic. 

Transporting Drugs Across the Southwest Border - Why A Border Wall Won't Work

Updated July 2019

Now that the Supreme Court's decision allows the Trump Administration to access funding for the southern border wall and with the southern border of the United States gaining a very significant portion of news coverage especially when it comes to Donald Trump's proclamations that the border region is a source of crime in the United States, a brief look at the 2018 National Drug Threat Assessment from the Department of Justice/Drug Enforcement Agency gives us interesting insight into how a border wall could impact the flow of drugs across the Mexico - United States frontier.

According to the 2018 National Drug Threat Assessment (NDTA), Mexico is a key source of the following illicit drugs:

1.) Heroin - Mexico is the primary source of heroin - significant increases in opium polly cultivation and heroin production allow Mexican Transnational Criminal Organizations (TCO) to supply high-purity, low-cost heroin into the U.S. market as U.S. demand has increased.

2.) Fentanyl and Synthetic Opioids - Mexico and China are the primary sources of the most lethal category of opioids used in the United States.  Fentanyl sourced from Mexico is generally lower in purity resulting in large seizures of  but larger in quantity than 

3.) Methamphetamine - most of America's methamphetamines are produced in Mexico and smuggled across the Southwest Border (SWB).

4.) Marijuana - Mexico is the most significant foreign source of marijuana with the volume of seized marijuana decreasing across the SWB.  Mexican drug traffickers are selling Mexico-sourced marijuana for use in THC extraction laboratories located in Southern California.

Overall, the Mexican TCOs remain the greatest criminal drug threat to the United States with the Sinaloa Cartel maintaining the largest footprint in the United States.  As well, in recent years, Cartel Jalisco Nueva Generacion's (based in Guadalajara) footprint in the United States has expanded substantially.

The report notes that Mexican TCO activity has the following structure and characteristics:

"Mexican TCO activity in the United States is mainly overseen by Mexican nationals or U.S. citizens of Mexican origin. U.S.-based TCO members of Mexican nationality enter the United States legally and illegally and often seek to conceal themselves within densely- populated Mexican-American communities. Mexican TCO members operating in the United States often share familial ties with, or can be traced back to, the natal region of leading cartel figures in Mexico. U.S.-based TCO members may reside in the United States prior to being employed by a Mexican TCO. In some cases, U.S.-based TCO members are given high-ranking positions within the organization upon returning to Mexico after years of successful activity in the United States."

They live among us!

According to the DEA, drugs are transported across the Southwest Border using the following methods:

"Mexican TCOs transport the majority of illicit drugs into the United States across the SWB using a wide array of smuggling techniques. The most common method employed by these TCOs involves transporting illicit drugs through U.S. POEs (official Points of Entry) in passenger vehicles with concealed compartments or commingled with legitimate goods on tractor trailers. In some instances, regardless of method, the size of the loads has decreased, while the number of them has increased.

Other cross-border smuggling techniques employed by Mexican TCOs include the use of subterranean tunnels, which originate in Mexico and lead into safe-houses on the U.S. side of the border. Underground tunnels are mainly used to smuggle ton quantities of marijuana, though there are instances of other illicit drugs commingled in shipments. Tunnels seized and destroyed by U.S. law enforcement authorities along the SWB are primarily found in California and Arizona, and are generally associated with the Sinaloa Cartel.

Mexican TCOs also transport illicit drugs to the United States aboard commercial cargo trains and passenger buses. To a lesser extent, Mexican TCOs use maritime vessels off the coast of California. Mexican TCOs also rely on traditional drug smuggling methods, such as the use of backpackers, or “mules,” on clandestine land trails to cross remote areas of the SWB into the United States.

Mexican TCOs exploit various aerial methods to transport illicit drugs across the SWB. These methods include the use of ultralight aircraft and unmanned aerial systems (UASs) and drones to conduct air drops. Ultralights are primarily used to transport marijuana shipments, depositing the drugs in close proximity to the SWB. Currently, UASs can only convey small multi-kilogram amounts of illicit drugs at a time and are therefore not commonly used, though there is potential for increased growth and use. Mexican TCOs also use UASs to monitor the activity of U.S. law enforcement along the SWB to identify cross-border vulnerabilities."

Let's take a more detailed look at the importation of heroin, one of the major imported drug classes, examining the DEA's views on how these drugs are transported from Mexico (and beyond) into the United States:

"In 2017, heroin from Mexico accounted for 91 percent (by weight) of the heroin analyzed through the DEA’s HSP.  The annual United States Government estimate of Mexican Poppy Cultivation and Heroin Production found poppy cultivation reached a record high in 2017. Poppy cultivation in Mexico rose 38 percent, from 32,000 hectares in 2016 to 44,100 hectares in 2017. Similarly, potential pure heroin production increased by 37 percent, from 81 metric tons in 2016 to 111 metric tons in 2017.

The SWB remains the primary entry point for heroin into the United States. Most of the heroin seized by Custom Border and Protection (CBP) occurs along the U.S.- Mexico border near San Diego, California.  In 2017, approximately 1,073 kilograms of heroin were seized in the San Diego corridor, a 59 percent increase over the total seized in 2016.  A small percentage of all heroin seized by CBP along the land border was between Ports of Entry (POEs). The CBP San Diego sector reported the greatest amount of heroin seized of all non- POE land border seizures, followed by the Tucson sector."

Here is a map which shows heroin seizures for each toe the Southwest Border regions for 2017:

"Mexican TCOs control the movement of heroin that enters the United States across the SWB, until it reaches its destination in cities all over the United States. The majority of the flow is through POVs entering the United States at legal ports of entry, followed by tractor-trailers, where the heroin is co-mingled with legal goods . Body carriers represent a smaller percentage of heroin movement across the SWB and they typically smuggle amounts ranging from three to six pounds taped to their torso, or in shoes and backpacks."

Here are some photographs from the report showing heroin concealed in privately owned vehicles:

"The majority of the cocaine and heroin produced and exported by Colombian TCOs to the United States is transported through Central America and Mexico. Colombian TCOs export large cocaine shipments to Mexico, Central America, and the Caribbean, using a variety of maritime and aerial means to include speedboats, fishing vessels, private aircraft, semi-submersibles, and commercial air and sea cargo."

Let's close this posting with an examination of the importation of fentanyl from Mexico.  As quoted here, Mexican fentanyl is of much lower quality than fentanyl imported from China:

"While seizures likely originating in Mexico represent the largest total gross weight of fentanyl seized in the United States, the overall low purity of this fentanyl means a relatively small portion of a given fentanyl seizure is actually fentanyl. Fentanyl sourced from China arrives in significantly smaller quantities than fentanyl sourced from Mexico, but due to its exceptionally high purity, it both poses a greater risk to the purchaser/user and can be adulterated many more times. DEA reporting also indicates Mexican traffickers order fentanyl from China, adulterate it, and smuggle it into the United States themselves, meaning an unknown amount of seized Mexican parcels containing fentanyl are ultimately of Chinese origin. In addition, Mexican traffickers’ primary source of supply for fentanyl precursor chemicals is also China."

Here is an explanation on the transporting of fentanyl across the Southwest Border:

"Fentanyl trafficked by Mexican TCOs is typically in multi-kilogram quantities and is combined with adulterants in clandestine facilities in Mexico prior to it moving into the SWB region. Mexican TCOs most commonly smuggle the multi-kilogram loads of fentanyl concealed in privately owned vehicles (POVs) before trafficking the drugs through SWB POEs. According to CBP and DEA reporting, although fentanyl is often seized as a part of poly drug loads (generally cocaine, heroin, and methamphetamine), fentanyl mixtures with other illicit drugs are very uncommon at the wholesale level."

Here is a quote on the amount of fentanyl seized in 2017:

"Fentanyl seizures at SWB POEs increased by 135 percent— from 223 kilograms to 524 kilograms— between CY 2016 and CY 2017. The CBP San Diego Field Office AOR remains the primary entry region for fentanyl entering the United States via the SWB (see Figure 41). Approximately 85 percent of the fentanyl seized— 447 kilograms of 524 kilograms— entering the United States via the SWB flowed through the San Diego POE in CY 2017. During this timeframe, personally operated vehicles were the conveyance for 74 percent of the fentanyl seized, by weight, at SWB POEs. The second largest volume of flow— 14 percent of all the fentanyl seized along the SWB— was seized in the CBP Tucson Field Office AOR in CY 2017. In comparison, during CY 2016, the CBP San Diego Field Office AOR accounted for 91 percent of all the fentanyl seized along the SWB and the CBP Tucson Field Office AOR accounted for nine percent."

Here is a map which shows fentanyl seizures for each toe the Southwest Border regions for 2017:

While I realize that the volume of drugs seized at the Southwest Border is likely a small fraction of the total drugs that cross the Mexico - United States border, it is interesting to see that the vast majority of both heroin and fentanyl is seized at official points of entry from either transport trucks or personal vehicles with only small volumes of these drugs being seized from individuals crossing the border illegally at points between official border crossings.  This would seem to indicate that the building of a continuous border wall will have relatively minimal impact on the volume of drugs imported into the United States from Mexico.  While a wall will make it more difficult for individual drug mules to smuggle relatively small volumes of illicit drugs into the United States, a wall is not going to stop people from importing illicit drugs using transport trucks, buses, personal vehicles and the myriad of other methods that involve crossing the border at official crossing points.

America's Biggest Failure in Afghanistan and its Global Consequences

As the war in Afghanistan drags on, approaching its 17th anniversary, we find that the Trump Administration, the third Administration that has fought America's longest war, is adapting this policy which was shared with the American people in August 2017:

"In Afghanistan and Pakistan, America’s interests are clear: We must stop the resurgence of safe havens that enable terrorists to threaten America, and we must prevent nuclear weapons and materials from coming into the hands of terrorists and being used against us, or anywhere in the world for that matter.

But to prosecute this war, we will learn from history.  As a result of our comprehensive review, American strategy in Afghanistan and South Asia will change dramatically in the following ways:

A core pillar of our new strategy is a shift from a time-based approach to one based on conditions.  I’ve said it many times how counterproductive it is for the United States to announce in advance the dates we intend to begin, or end, military options.  We will not talk about numbers of troops or our plans for further military activities.

Conditions on the ground — not arbitrary timetables — will guide our strategy from now on.  America’s enemies must never know our plans or believe they can wait us out.  I will not say when we are going to attack, but attack we will.

Another fundamental pillar of our new strategy is the integration of all instruments of American power — diplomatic, economic, and military — toward a successful outcome.

Someday, after an effective military effort, perhaps it will be possible to have a political settlement that includes elements of the Taliban in Afghanistan, but nobody knows if or when that will ever happen.  America will continue its support for the Afghan government and the Afghan military as they confront the Taliban in the field."

With the knowledge that the United States is not going to leave Afghanistan anytime soon, let's look at one of the greatest untold failures of the 17 year mission; controlling Afghanistan's drug trade, a failure that has had repercussions throughout the world.  Thanks to the United Nations Office on Drugs and Crime (UNODC), we get an annual summary of the world of illicit drugs, most particularly, drugs coming from Afghanistan.  In this posting, I will source data from the 2018 edition of the World Drug Report with additional data being sourced from UNODC's Afghanistan Opium Survey 2017.

Let's start by looking at opium poppy cultivation in Afghanistan, the source for much the world's heroin supply.  In 2017, a record high of 328,000 hectares of land was cultivated for opium poppies, up from 201,000 hectares in 2016 with 11 percent of all opium poppy farmers reporting that they had cultivated opium poppies for the first time in 2017.  Since yields were very good, potential opium production doubled from 4800 tons in 2016 to 9000 tons in 2017 or 85.7 percent of the world's total of 10500 tons.  It is estimated that 7600 to 7900 tons of this opium was available for heroin production with the remaining 1100 to 1400 tons being consumed as raw opium in the region.  The 7600 to 7900 tons of opium will form the base for the production of 550 to 900 tons of export quality heroin (with 50 to 70 percent purity) and 390 to 450 tons of pure heroin base.

If we look back in time, we find that since 2006, the areal extent of opium poppy production in Afghanistan has varied significantly but has never really declined for any length of time:

Additionally, it is interesting to see that in 2017, Afghanistan was responsible for 78 percent of the global area under cultivation for opium poppies, a number that has varied from 65 to 82 percent since 2006.

The massive increase in opium poppy cultivation is related to several factors including political instability, lack of government control and security and socio-economic factors including poor employment opportunities for farmers, lack of education and limited access to markets for other agricultural products.  Cultivation of opium poppies created the equivalent of 354,000 full-time jobs for workers hired by farmers to weed, lance and harvest the poppy crop.  Opium poppy farmers use income from their poppy crops to pay for food, debt and medical expenses with very few farmers using the proceeds of their poppy crop to pay for additional property, education or other activities that would allow them to diversify from growing poppies as shown on this graphic:

Here is a map showing the main opium poppy producing regions in Afghanistan with larger producing regions in darker green:

Here is a table showing the percentage of villages (by region) with poppy cultivation:

Here is a table showing the value of the opium poppy to Afghanistan's overall economy:

Here is a graphic showing the value added to the Afghanistan economy from the agricultural sector as a whole and opiate export sector since 2000:

Here is a graphic showing the farm-gate value (in $millions) of opium production in Afghanistan from 2008 to 2017:

It is quite apparent that nearly two decades of war has done very little to stifle the importance of the opium poppy crop to the economy of Afghanistan, despite the presence of coalition military forces fighting the never-ending war against terrorism.

While there has been some eradication of poppy growing areas, the areas are very small compared to the total with only 750 hectares eradicated over the entirety of 2017 and only 60581 hectares being eradicated since 2016.

As you can see from the data in this posting, the War on Terror which began in Afghanistan in 2001 has been an abject failure when it comes to destroying Afghanistan's ability to flood the world with its home-grown opiates.  Even more interestingly, taxes paid by opium poppy farmers on their crops (paying ushr) often end up in the hands of the Taliban and other anti-government/insurgency groups, a situation that has made it even harder for the Afghani central government to control one of America's nation-building experiments.  Unless the United States makes a deliberate effort to control the opium poppy marketplace in Afghanistan under its new strategy which will reflect conditions on the ground rather than arbitrary timetables, the nation will continue to be a source of funding for both the Taliban and terrorist groups.  Not only that, but the failure of the coalition forces to reign in the production of opium poppies has certainly not helped to reduce the growing global opioid crisis.

The Failure of Big Pharma

The high cost of pharmaceuticals in America seems to crop up on the mainstream media's radar screen on occasion, however, recent data shows that the problem with Big Pharma goes far beyond pricing.

A recent article by Liz Szabo on the Kaiser Health News website gives us an interesting perspective on the cancer drug business.  According to Ms. Szabo, demands for earlier access to potentially life-saving oncology drugs has led to a flood of FDA-approved pharmaceuticals hitting the marketplace; that said, many of these new drugs are extremely expensive and offer patients marginal benefits.  In fact, the 72 new cancer therapies that were approved by the FDA offered patients a life extensions averaging only 2.1 months.  As well, two-thirds of the cancer drugs approved in the last two years have no evidence showing that they extend life at all.

A recent study by Tracy Rupp and Diana Zuckerman found that for 18 of the 36 drugs that were approved between 2008 and 2012, post-marketing studies showed that there was no "overall survival benefit".  Here is a table showing the drugs in the study, ranked by whether they improved the patient's quality of life, the type of cancer treated by the drug and the drug's annual cost:

Please note that only one drug actually improved the patient's quality of life while six showed no statistical difference, four had mixed results, two actually made the patient's quality of life worse and five had no evidence.  It is also interesting to note that the average annual costs for the drugs (whether they worked or not) ranged from $20,237 to a tear-jerking and wallet-opening $169,680.

While we are on the subject of the cost of these effective and not-so-effective cancer drugs, let's look at what has happened to the monthly and median price of cancer drugs between 1965 and 2016:

Here is a complete listing of the drugs, the monthly cost at the time of approval and the monthly cost in 2014 dollars:

In 2014 dollars, monthly cancer drug costs for drugs approved back in the 1960s range from $13 to $1,158.  The monthly cancer drug costs for the drugs released over the past five years (from 2011 to 2016) range from $5,535 to $64,260.  That's right, over $64,000 for a single month's worth of Blincyto, an injectable drug that is used to treat Ph-negative relapsed or refractory B-cell precursor acute lymphoblastic leukaemia.  The manufacturer, California-based Amgen, the world's largest independent biotechnology company, claims that clinical trials show that "41.6 percent of patients achieved a complete remission or complete remission with partial hematological recovery during the first two treatment cycles."  In case you were curious, Amgen's adjusted net income for 2015 was $7.954 billion, up from $6.7 billion in 2014 on sales of $20.944 billion.  The company spent and adjusted $3.917 billion on research and development. 

When you compile the information in this posting, you find that patients suffering from cancer are paying far more for drugs that, in at least some cases, provide marginal benefits when it comes to extending life.  The data also shows that the cost associated with these drugs can be considered nothing more than immoral, particularly when they are designed for use in cases where patients' lives are already threatened and they are at their most vulnerable, facing their own mortality. 

Illicit Drug Use in America and the Failed War on Drugs

The Substance Abuse and Mental Health Services Administration looked at national drug use in its latest report for 2014.  In its report, SAMHSA found that drug use continued to rise as you will see in this posting.

Approximately 21.5 million Americans (or 10.2 percent of the population) aged 12 or older in 2014 had a substance use disorder (SUD).  This includes 7.1 million that had an illicit drug use disorder and 2.6 million who had both an alcohol and illicit drug use disorder.

Here is a graphic showing the number of past month illicit drug users in 2014:

Here is a graphic showing past month illicit drug users by year and how it has gradually risen over the past decade and a half:

The rise in illicit drug use among those aged 12 and older since 2002 reflects an increase in illicit drug use by adults aged 26 and older for the most part.  

Interestingly, an estimated 22.2 million Americans aged 12 and older in 2014 were current users of marijuana, corresponding to 8.4 percent of the population of that age group.  This is up from levels seen between 2002 and 2013 as shown on this graphic:

Here is a graphic showing the past month non-medical use of psychotherapeutic drug including pain relievers, tranquilizers, stimulants and sedatives for people aged 12 and older:

Even though heroin has no medical use in the United States, there are about 435,000 current heroin users which represents about 0.2 percent of the population as shown on this graphic:

If you look carefully at the graphics, you'll note that the use of illicit drugs is most prevalent in the aged group between 18 and 25.  It is, however, interesting to note that there is significant drug use among those aged 12 to 17 and that illicit drug use has risen by a couple of percentage points over the last decade and a half.

So much for that multi-decade War on Drugs which has cost over $17.3 billion in 2016 (combined state and federal expenses) or $500 per second according to Drug Sense.