Mexico’s president has been the first North American leader to call for the outright ban of the medical use of fentanyl, as relationships between his country and its northern neighbour sour through the handling of the overdose crisis.
The traffic of fentanyl from Mexico across to the US has strained relationships between both countries: Mexican President Andrés Manuel López Obrador has stated in the past that his government is doing more to control the drug than their northern neighbours, and that the American overdose crisis is more related to the decay of family and moral values than about the drugs.
Fentanyl in North America is the iron law of prohibition in action
While concerns with drug deaths involving fentanyl are important to highlight, banning their use from medical contexts will do nothing to stem deaths. This is primarily because fentanyl is adulterating the heroin (and increasingly other substances’) supply. As a potent substance, small quantities of it can be mixed into -or entirely replace – many drugs to potentiate their effects. However, this can have deadly effects as consumers are not aware that this is going on unless they test their drugs. Since its introduction into the North American heroin and benzodiazepine drug supply (which happened as early as 2014), fentanyl has come to dominate drug markets.
Fentanyl’s infiltration of the North American market is an example of the iron law of prohibition in action. Decades of aggressive marketing of opioid medication like OxyContin to North American patients, as well as lax regulation on prescribing, created a massive demand for this class of drugs. After the American Centre for Disease Control and Prevention restricted the prescription of opioids in 2016, cracking down on pill mills and excessive prescribing, the disappearance of a safe supply of this drug alongside massive demand created the perfect conditions for a potent, easily imported and manufactured substitute to appear.
Reports from the Drug Enforcement Agency (DEA) have shown fentanyl primarily coming into the US from China and Mexico. Precursor chemicals were also imported from China to the US for national production; however, stringent controls put in place by the Chinese and Hong Kong government in 2019 have reduced the flow of these chemicals into the country. While China remains an important source for fentanyl precursors, researchers from the Wilson Centre and InSight Crime acknowledge that Mexico’s role in transiting and producing fentanyl for US origin has come to grow significantly. This is mostly organised by the Sinaloa and New Generation Jalisco (CJNG) cartels, who have the capital to mass procure and produce fentanyl; smaller criminal organisations are then responsible for their smuggling and distribution across the US. This further highlights that fentanyl use is stemming primarily from imports rather than diversion from pharmaceutical sources, which is the reason behind Obrador’s ban.
While the Wilson Centre and InSight Crime state it is unclear “how much Mexico-sourced fentanyl is being consumed in the United States”, the US State Department have blamed Mexico’s lack of controls over fentanyl as a catalyst for drug-related deaths, declaring that 96% of American fentanyl has entered the country through Mexico. Analysts from the Brookings Institute have also said there is “minimal to nonexistent law enforcement cooperation” between both countries, further preventing any meaningful barriers to its entry.
Controversially, President Obrador has claimed that no fentanyl is produced within Mexico, further opining that the high number of deaths is because American parents don’t hug their children enough: “There is a lot of disintegration of families, there is a lot of individualism, there is a lack of love, of brotherhood, of hugs and embraces”.
And while there have been some high-level agreements for greater cooperation between Canada, Mexico and the US to address fentanyl, the lack of cooperation is not aided by these statements from each side.
The pain of counterfeit pills in pharmacies
Tensions further flared with the appearance of counterfeit opioid medication in Mexican pharmacies have come to strain the relations between the North American nations. According to NPR, some Mexican drug stores sold counterfeit oxycodone pills which have tested positive for fentanyl and heroin. This happens in stores that primarily cater to American tourists who travel to Mexico for cheaper medicine.
How this happened is still unclear. “I think it’d be really important to do some testing, some substance analysis on drugs that are bought in pharmacies to see if there has been cross-contamination. I would think that there has been some sort of cross-contamination of fentanyl with other pills and maybe within a semi illegal space – that those pills are not being or not being produced within legal markets, but rather kind of in clandestine spaces,” said Zara Snapp, the founder of Instituto RIA, which conducts research into safer public policies in Mexico.
“I think it’s really important to be clear that there are two separate markets that exist. So there’s the medical fentanyl market, which obviously has a different way of presenting fentanyl for people to use in the terminal stages of cancer primarily to relieve pain. And then there’s obviously an illegal market of fentanyl, which is adulterating the heroin and the heroin market primarily,” she added.
Cracking down on the medical use of fentanyl would most likely not impact the number of people dying from its use, as the majority of the recreationally used fentanyl comes from an altered heroin supply, rather than pills that have been diverted from a legal supply.
“I have heard zero cases of diversion from the medical fentanyl market to the illegal fentanyl market, both because of its presentation, its mode of administration and the dosage. Whereas we obviously know that fentanyl is very present in the illegal market. And that that has whole different supply chains, primarily with precursors from China, or Asia, into Mexico, where then they’re packaged, and sent to the United States” Snapp explained to TalkingDrugs.
One of the most significant consequences of restricting medical supply of fentanyl would be an exacerbation of a serious lack of options for pain management. Mexico has struggled to fulfil the demand for medicinal use of opioids for a decade: it ranked last in terms of opioid availability among the 37 member nations of the Organisation for Economic Co-operation and Development between 2011 and 2016. Research into opioid use across North America in 2015 estimated that only 35% of Mexico’s palliative care needs were met, compared to 3,150% in the US, and 3,090% in Canada. Although the government boosted prescription efforts for opioids in 2015, they were still severely under-prescribed for those with a severe and immediate need; it appears far-fetched to assume that this medicine is being diverted for recreational purposes when there’s not enough going round for patients.
President Obrador’s move to further restrict fentanyl’s medical use is part of a worrying North American approach to opioid control, which will aggravate a very real and pressing pain crisis for patients in the continent. The World Health Organisation has raised how the “focus on restricting appropriate medical use of opioids has harmed many US residents living with cancer and other diseases”, with a further ripple effect across the globe as American drug policy decisions are often adopted by other nations.
Questioning the validity of fentanyl’s medical use stokes the fear around overdoses by equating it to any use of this substance, unfairly criticising its very valid use in medical settings. As Snapp commented, “the declarations of the president are really based in lack of knowledge, but in a fear mongering, ‘how do we push out fear to society’ and people are scared, and they’re all saying, ‘How will I know if there’s fentanyl in a medication that I’m taking?’”
Obrador’s approach is not only misdirected, it will clearly exacerbate an existing palliative care crisis in Mexico, one of pain that is left throbbing through Mexican society. Its impact on fentanyl sources in the continent will be minimal; instead, it is patients that need strong painkillers that will feel the sting of his brash decision.