Webinar

Reporting on Fentanyl and the Opioid Crisis

Thursday, July 20, 2023
Speakers

Senior Fellow, Center for 21st Century Security and Intelligence, The Brookings Institution

Los Angeles Times

Presider

Senior Fellow, Council on Foreign Relations

Introductory Remarks

Vice President for National Program and Outreach, Council on Foreign Relations

Vanda Felbab-Brown, senior fellow at the Brookings Institution, discusses policies aimed at ending the opioid crisis, challenges to stopping the flow of fentanyl across borders, and how this affects the relationship between the United States, China, and Mexico. Sam Quinones, author and freelance journalist, discusses his experience covering fentanyl trafficking and framing local stories on the opioid epidemic. The host for the webinar is Carla Anne Robbins, senior fellow at CFR and former deputy editorial page editor at the New York Times.

FASKIANOS: Thank you. Welcome to the Council on Foreign Relations Local Journalists Webinar. I’m Irina Faskianos, vice president for the National Program and Outreach here at CFR.

CFR is an independent and nonpartisan membership organization. think tank, publisher, and educational institution focusing on U.S. foreign policy. CFR is also the publisher of Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy. This webinar is part of CFR’s Local Journalists Initiative created to help you draw connections between the local issues you cover and national and international dynamics. Our programming puts you in touch with CFR resources and expertise on international issues and provides a forum for sharing best practices.

We appreciate your taking the time to be with us today for this discussion. The webinar is on the record. The video and transcript will be posted on our website after the fact at CFR.org/local journalists,

We are pleased to have Vanda Felbab-Brown and Sam Quinones to lead today’s discussion with Carla Ann Robbins. Vanda Felbab-Brown is a senior fellow in the Strobe Talbott Center for Security, Strategy, and Technology in the Foreign Policy Program at Brookings Institution. She’s an expert on international and internal conflicts and nontraditional security threats, including organized crime and illicit economies. And she serves as co-director of the Brookings research project The Opioid Crisis in America: Domestic and International dimensions,” which publishes a series of papers to address opioid addiction and weaknesses in U.S. drug policy and health systems.

Sam Quinones is a freelance journalist, author, and public speaker. He lived in Mexico for ten years as a freelance reporter covering Mexican politics, immigration, and drug trafficking. He also spent ten years as a reporter for the L.A. Times. And most recently, he has authored two books on the opioid epidemic Dreamland—The True Tale of America’s Opioid Epidemic, in 2015, and The Least of Us: True Tales of America and Hope in the Time Fentanyl and Meth, in 2021.

And our host is Carla Ann Robbins. She’s a senior fellow at CFR. She’s the faculty director of the Master of International Affairs Program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. Previously, she was deputy editorial page editor at the New York Times and chief diplomatic correspondent at the Wall Street Journal. I’m going to turn it over to Carla to lead the conversation. And then we’ll go to all of you for your comments and questions. So, Carla, over to you.

ROBBINS: Irina, thank you so much. And, Vanda and Sam, thank you so much for doing this today.

Sam, can we start with you and with some basics? What’s fentanyl? Is it more dangerous and addictive than other opiates? And why is this epidemic different from other—sorry—other drug epidemics, or is it?

QUINONES: Well, fentanyl is actually a magnificent drug and very important to keep that in mind. I’ve had something myself and, in the surgical setting, it has revolutionized surgery. Made it far easier to do certain surgeries, and been a workhorse drug, particularly in cardiac surgery. I had a heart attack six years ago and was given fentanyl then. So it’s very important to keep in mind that this is a workhorse, revolutionary drug that really has done a lot of good for humankind.

Of course, when this—what makes it a great drug, and aesthetically, is also what makes it a problem when it’s controlled by the underworld. And that is, first thing, it’s enormously potent and much more potent than heroin. It’s an opioid, although it’s made, not grown from the—or taken from the opium poppy. It’s made with chemicals. It’s a synthetic drug—fully synthetic drug. And the other thing about it is—that makes it a wonderful drug surgically—is that it takes you in and out of anesthesia very, very quickly.

That’s exactly what makes it a disaster on the street, because then—for two reasons. One, users tend to have to always be using fentanyl all day long, because of that. And also, traffickers see it as a magnificent addendum to their offerings, and have added it to cocaine, and meth, and marijuana. And what they frequently end up doing, killing a few people—killing some people along the way, but also creating full-time multi-purchase daily addicts from people who used to be, at one point, may be occasional cocaine users. And that is—a lot of this was just simply the function of the amount of fentanyl that’s now coming in, primarily from Mexico, across the United States.

So really, we’re seeing now fentanyl cover the United States. It was not the case, say, in 2014-15, those years. You saw it mainly confined to the areas where the opioid epidemic, that I wrote about in my Dreamland book, was really the issue. Then the Mexicans really got involved big time, and more and more people learned how to make it, and the ingredients to make it were—became very plentiful, imported in from China. And you began to see an explosion of supply. And so you saw going from the Midwest, to both coasts, and across the country. So now you find fentanyl all over the United States, along with methamphetamine, another synthetic drug that is made in similar kind of quantities.

And that’s also what makes this a very different situation. We have never seen two drugs—I really pair them together; it’s hard to separate them, in my opinion—two drugs of such potency, such prevalence, such low price nationwide, and was such devastating effects. Of course, fentanyl is a highly deadly drug when used in this way. Methamphetamine, in the intense purity that it’s coming in from Mexico, the intense potency it’s coming in from Mexico, has really shown itself to be transformative in, particularly, creating very rapid-onset symptoms of schizophrenia, and very often homelessness, and this kind of thing.

And so that’s a very brief summary of these two drugs, because I have trouble separating them, really. I think they’re all kind of part of the same story. But certainly, fentanyl is the most deadly drug we’ve ever seen on our streets, particularly given the supplies and the prevalence that we’re seeing it now, nationwide.

ROBBINS: So can you be a—I don’t mean you personally—but can one be a casual fentanyl user? Or is it the sort of thing that you take and you very quickly get addicted?

QUINONES: With the supplies that we’re seeing now I think it’s very difficult to argue that you could do that. I think that the—I mean, I’ve known—

ROBBINS: But I mean, just chemically. I mean, biologically.

QUINONES: I think it’s such a potent drug that it’s very difficult to achieve that. There’s very—I mean, if you have the supply reduced and you can’t get access to it, then perhaps. But I believe that with the supplies that we have today on the street, it’s very difficult to be a functioning fentanyl user. I’m sure there are some, but I don’t think that’s the norm. The other truth is, I think, very clearly on the streets of America today, that there is no such thing as a long-term, fentanyl addict. They all seem to die. Now, if you looked at heroin, I’ve known heroin addicts that used heroin for twenty, thirty, forty years, and a very—and, you know, they don’t have a great life, but you know, they’re not dead. I just don’t see that with fentanyl, given, again, the supplies that we’re seeing coming in from Mexico now.

ROBBINS: So, thanks. Vanda, can we talk about the international component of this? Sam mentioned it coming from Mexico, but most of it originates—either that, or the precursor chemicals—originate in China. Can you talk about the supply chain and the particular challenges of trying to stop something that, I suppose, the precursors are dual use chemicals?

FELBAB-BROWN: I will. Let me just add a few comments to expand on Sam’s points and your original question, Carla. So fentanyl is a very dangerous drug. It’s at least fifty times as potent as heroin. And other varieties and analogs of fentanyl-type drugs can be many more times as potent. Carfentanil is at least a hundred times as potent. That has two effects, it induces substance use disorder, popularly known as addiction, extremely rapidly with very limited exposure.

It also means that the lethality, the chance of overdose, is very high, particularly as many users who are sourcing any kind of opioids—whether it’s oxycontin or whether they’re sourcing completely other drugs such as cocaine, a very different type of drugs—these days, not just in the United States but also in Canada and in Mexico, often end up buying a mixture that has fentanyl. So fentanyl can be used as an adulterant in a whole variety of drugs.

Fentanyl is enormously attractive from the perspective of suppliers. And this is indeed the most lethal epidemic ever in human history. And we are heading into much greater lethality rates as fentanyl is spreading, will spread beyond North America. But already as it is, it’s the most lethal epidemic ever in human history, affecting wide segments of population. Not just your typical entry user into recreational drugs, but causing in the United States four times, five times as high of lethality in people over sixty-five. Something we have never seen with any other drug.

But even though it’s this dangerous, it’s enormously attractive for traffickers because of the potency per rate ratio, which makes it very easy to source it. And here’s where I’m coming to the supply chain. Very small amounts of precursor chemicals are needed to produce fentanyl. Just a small fraction of the chemicals needed for heroin or cocaine. And the same also is true on the finished product. So the rule of thumb is that it takes about ten trailer trucks of cocaine or heroin to supply the U.S. drug market for a year. Well, it will take one trailer truck of fentanyl, on tenth or less than one tenth.

Now, obviously, no trafficking organization, certainly not the Sinaloa Cartel and Cártel de Jalisco Nueva Generación, are going to send one full trailer truck of cocaine. They will disperse the amounts. But the detection problem from precursor source all the way to retail are enormously grown. And this then is a drug that has been pushed to users not as a result of demand. This epidemic is driven by supply, because it’s so convenient for traffickers. And this is part and parcel of the synthetic drug revolution that is sweeping global drug markets. It’s sweeping East Asia. It’s emerging in Africa. It’s causing countries like Afghanistan with all its poppy, at least until the Taliban ban and its enforcement a year ago, to be producing meth.

So what does the supply look like? Precursor chemicals originate predominantly in two places, India and China. The vast majority still in China. And today, just like with methamphetamine, about which Sam spoke, the precursors are mostly what is called pre-precursors. So very basic chemicals that have enormous use in any kind of legal chemistry, agricultural products, pharmaceutical products. As a result, they are enormously difficult to control. Many of them, the vast majority of the pre-precursors available today, are not scheduled. That means there are minimal controls.

Nonetheless, it’s also very obvious that Chinese suppliers knowingly, directly, purposefully sell to Mexican criminal groups. That they don’t sell to a legitimate outlet not knowing that they were somehow diverted from them to the Sinaloa Cartel. There is knowing complicity. The Mexican groups then—the two predominant, Sinaloa and Jalisco, control the production—more or less have a duopoly on the production in Mexico. Despite the fact that President Lopez Obrador says there is no fentanyl produced in Mexico, they synthesize fentanyl in Mexico.

And then they smuggle it into United States, whether in its highly concentrated form or various adulterated forms. Sometimes the mixing into other drugs takes place in the U.S. Other times, fake oxycodone pills which contain fentanyl are sent from Mexico to the United States. The latest development is first—or early attempts, is the better way to phrase it—especially by Sinaloa Cartel—to push production to other areas like, Guatemala and Colombia.

ROBBINS: So—

FELBAB-BROWN: And my opening statement here is—

ROBBINS: Please, yes.

FELBAB-BROWN: Despite the fact that the supply chain is still very concentrated and clear, you know, it’s mostly China-Mexico-United States. That is some role of India and that can grow and you can have other countries that become sources of pre-precursors, it’s still a fairly straightforward line, there, unfortunately, is no meaningful cooperation between China and United States and between Mexico and the United States. In the first place, the relationship was always very weak, China-U.S., but completely collapsed as a result of the geostrategic tensions. And in the case of Mexico, the counternarcotics cooperation became completely eviscerated by the López Obrador administration.

ROBBINS: So I’m going to want to get more into those two relationships and what policy could possibly do, but wanted to go back a little bit about this notion of supply and demand and push and pull. Because, you know, for the longest time people who said that, you know, the number-one way to control a drug is for treatment. And is this different? And are—and, first of all, is the Biden administration doing a better job on treatment programs? Or is this just going to be overwhelmed because just—there’s just so much supply out there? Is this really something that’s got to be mainly a criminal or geostrategic and criminal problem to be solved that way? And, Sam, first over to you on that.

QUINONES: Well, I would very much agree with Vanda on this. This is a case of supply creating demand. I think I wrote about it in my book, and then a story recently for the Atlantic. I absolutely think that’s what the evidence shows, and my reporting shows as well. What I think it then requires—as they say on the street, fentanyl changes everything. I would say the same thing is true of methamphetamine. There’s very little about the drug situation today that bears any kind of resemblance to the plant-based drug problems that we had, you know, fifteen, twenty years ago, or what have you.

And so I do believe that, as Vanda said, that—well, first of all, that there is almost no collaboration or cooperation between the governments. She mentioned ours, Mexico, China, which is a real problem. We also have a problem, I think, in our country with the lifting of the ban on the commercial sale of assault weapons. And I think a lot of those assault weapons now are going down to Mexico, where they serve to ensure the impunity of a lot of the groups, as well as foment the violence that’s been going on down there since about 2005. Our ban ended in 2004, and the cartel wars in Mexico, I think, really begin to take root in in 2005. And I leave that to other people, whether they think that’s a coincidence or not. But I think that’s what’s going on.

I do believe that at the local level we have also, in various parts of the country, tried to apply policies—counties, cities, public health-type policies that that may have made sense in another era, and I don’t believe they make sense in a time now where the least little exposure to a drug means you very likely could be—could die. And I think the turning away from law enforcement has been a big, big mistake. The criminalization of sale of fentanyl, for example.

Anything containing fentanyl in many parts—in certain parts of the country, anyway, you find that to be almost a—basically a misdemeanor, even though selling fentanyl—I mean, selling something that contains fentanyl is like shooting a gun into a crowd. You know, you’re going to hurt somebody, you’re probably going to kill somebody. Yet we still have these ideas of how to approach this that were conceived in another era. And I think decriminalizing this stuff—I also—is part of that.

I think that another thing that I have been focusing on, simply because I don’t see anybody else doing it, and I find that my reporting has been—I’ve been very interested in this topic. And that is how, in an age of fentanyl and meth, it makes jail an essential element of our approach to this. And many parts of the country, jail is being rethought so it’s actually a recovery center, but you just can’t leave. And that’s the crucial thing about jail. And in a time when you’re on—when you’re—people are addicted to fentanyl and meth, drugs that are dominating their brain chemistry so totally that they won’t leave the street, they’re not—they’re never going to be ready for treatment, the way we’ve traditionally conceived it.

They need to be off the street, away from the drugs, and then they have a chance—they have a fighting chance to develop readiness. That’s what you’re finding when people are in these jails. And there are some around the country that are doing this. As I said, it’s a very interesting thing to watch. And so I think that this is—you know, these are—this is part of what these two drugs are changing in the United States.

I do believe, having lived in Mexico ten years, wrote two books about the country, that a deeper collaboration with Mexico is absolutely essential. I also believe that the current president of Mexico is, I’ll try to find a charitable way of putting it, but not up to the job—(laughter)—on this, or not up to recognizing what the issues are and the implications are of all that he’s facing.

ROBBINS: Vanda, you mentioned—and, Sam, thank you for that. And I’m sure you want to have some comment as well about domestic and local policy about this. But can we talk a bit about the Chinese before we turn this over? Why does the Chinese government enable this? I understand that why they might not want to make us happy, because we have a rather strained relationship with them, as we’re cutting off their supply of advanced chips and lots of other competition going on there. But is it that they don’t—you know, they don’t have a problem at home? I mean, their neighbors have problems and I’ve been criticizing them about it. Is it that there are high ranking Chinese officials who are in the business and so they have a corruption interest in it? I mean, what is the game for the Chinese?

FELBAB-BROWN: Yeah. I’ll definitely speak about China. And there’s a lot to unpack in China’s role and/or complicity. And I’ll come to that. Is it complicity? What is China’s role? But let me little bit speak about demand and, again, just complement some of the things that Sam said.

So, look, demand reduction, which consists of treatment and prevention, is absolutely essential. It is what needs to underpin any kind of response to dealing with any drugs. That is true also about synthetic drugs like opioids, like synthetic opioids, like fentanyl and methamphetamine. There is also a significant role for what’s called harm reduction measures. But they are insufficient in and of themselves.

And this epidemic, I think, very potently drives home two messages: The notion that the drugs are problematic only because they are illegal, that prohibition is the source of all evil, is being fundamentally challenged, in my view debunked, by what’s happening with the fentanyl and synthetics opioid epidemic. And for that matter, even with meth. (Laughs.) But also that harm reduction measures are sufficient.

Now, there are fundamental differences between meth and between opioids like fentanyl. So the one good news in the fentanyl epidemic has been that there are quite effective both harm reduction and treatment measures for opioids. You have the possibility of methadone replacement—very effective strategy. And you have overdose medication—Buprenorphine in popular parlance the brand name Narcan—that has reversed lethal overdose.

If we haven’t had Narcan, the amount of—the actual amount of overdose is about five times higher than the amount of death. So last year, we had about 107,000 deaths in the United States. The actual number of overdoses was five times that number, almost 600,000, 550,000. But Narcan and its availability have saved the lives, or reversed the overdose. That doesn’t mean that someone who had an overdose and received Narcan will be just fully fine functional, as if nothing happened. People can carry long term morbidity effects.

Methamphetamine is different. We don’t have overdose—although overdose is not so much an issue, even super-potent methadone. We don’t have the same replacement drugs. There is no equivalent to methadone in the meth space. And meth, especially in the highly—super-potent Mexican meth that Sam spoke about, creates very rapidly, very bad morbidity effects. So not only does it create addiction or substance use disorder, it also creates quite rapid, very difficult morbidity effects. The whole body is physically very affected. So the harm reduction measures we have for opioids we don’t have.

Now the story gets more complicated. And that’s the introduction of xylazine tranquilizer into the U.S. drug market, including into fentanyl. Xylazine can eviscerate the effects of Narcan. And it also now complicates the morbidity picture, not the mortality but the morbidity picture, of opioids. It makes opioids have very high morbidity effects, such as, you know, people—the necrotic tissue, with these horrible images that you’re starting to see.

There is—and one important dimension of it is—so you asked, you know, is the Biden administration doing enough? There has been significant progress in U.S. policy on attitudes towards treatment and harm reduction. It started already during the Trump administration, not because of the White House and the wisdom of the Trump administration, but because state and localities started piloting, experimenting with measures such as safe needle exchange, safe injection sites, and the availability of Narcan. So at the local level, already during the Trump era there was a break with the doctrinaire, rigid, absolutely no harm reduction measures typical of U.S. policy.

The Obama administration before significantly helped treatment because of the way that it changed and demanded mandatory access to various public health measures that often made it impossible for people with substance use disorder to access the medical system. And in the Biden administration, those trends have just continued. The Biden administration very explicitly embraced these public health responses.

So much so that one would even argue that we found ourselves in a paradoxical situation that until maybe half a year, three quarters of a year ago, most of U.S. policy toward fentanyl was not on the supply side, was very soft approach—a very soft approach both with AMLO and with China on this specific issue. There have been lots of highly contentious relationship with China. But it also showed how limited this response is. And I often point people to the fact that Vancouver, British Columbia have some of the most robustly funded and most expensive harm reduction measures of any locality in the world. Yet their opioid overdose is on par with West Virginia, one of the worst affected U.S. localities.

So let me come to China. So yesterday, I was doing a hearing and some of the Republican witnesses, some of my fellow witnesses, were making the comment that China is on purpose poisoning the United States. This is a form of asymmetric warfare, a strategy to kill off as many Americans as possible. And I don’t think that anyone can make the statement unless they have access to, you know, wiretap communications from the Politburo and Xi Jinping to, you know, top Chinese decision makers. China nonetheless, I have argued and showed in my research, very strongly subordinates all forms of law enforcement cooperation to the geostrategic relationship.

And this is not true just about the U.S. It’s its attitude toward other countries, from Australia to Vietnam to Cambodia to, you know, Thailand—pick your country. China extents law enforcement and counternarcotics cooperation when it seeks to court the country or when in hopes it will generate strategic payoffs. And when those strategic payoffs don’t materialize, and they have not during the Trump administration or during the Biden administration, China withdraws from the cooperation.

Now here, we need to separate the drugs. China has enormous problems with meth use. But even despite the fact that China has enormous problems with meth use, and the Chinese Triads are the principal dominant suppliers of meth across the Asia-Pacific region, China has also very complex relationship with the Triads. Chinese government official use the Triads for a whole variety of unofficial services. The Triads act as extralegal enforcers, they oil corruption with government officials in other countries. There is a relationship, not one of command but one of mediation, one of management.

Nonetheless, China has not had a problem with synthetic opioids. It has a heroin problem. Its heroin is supplied out of Afghanistan and, most importantly, out of Myanmar. But it hasn’t had a problem with synthetic opioids. And so China’s formal posture tends to be: We cannot control precursors because they’re not scheduled. And by the way, the United States, this is your problem. It’s your decadent society. It’s your evil pharmaceutical companies—which are, indeed, evil in the way they unleashed the opioid epidemic. (Laughter.) It’s your problem. It’s not ours. And to the extent that we have extended cooperation, like scheduling the fentanyl-class type of drugs in 2019, we did it as this grand humanitarian gesture toward you.

ROBBINS: So I want to turn it over—and this is hugely helpful. I want to turn it over to the group. And, please, you know, get ready with your questions, either raising your hands or putting them in into the Q&A, and we’ll call on you. But, Sam, really quickly, you talked about, you know, disappointment with AMLO. You talked about—but you’ve also written about the possibility of much greater cooperation between Biden and the current Mexican president. How does, you know, we’ve heard a lot of the things that the Vanda is saying about the Chinese perception of the United States, we’ve heard this from the Mexicans in the past as well. It’s your problem. It’s your consumption issue. It’s, you know, not—and then you add on to the fact that we are a major supplier of guns. I mean, how does this current government in Mexico see it? Is it a corruption issue? And, you know, you have to get inside their psychology before you can imagine what levers to pull to try to get better cooperation.

QUINONES: Right. It seems to me that there is a combination of blithe disregard, unwillingness to actually do much more than control immigration flows for the United States. Part of this, I think, has to do with the leftist history of Andrés Manuel López Obrador. Also I would say, when I was in Mexico I covered him. He was mayor, he was Senator. At the time he seemed a very coherent, articulate member of the left, and was able to enunciate and articulate strategies that I thought were, you know—you know, he did that well. I would say, it does not seem that he does that anymore.

He seems, in fact, almost, again, trying to be charitable, but, you know, it does not seem like he is in control of his full faculties. And I think that is part of the problem. His parent—I won’t say obedience, but certainly his collaboration with the military in ways that that make me question the reasons behind it are strange. And so, you know, I would say that we certainly have a lot on our side to question. And I would say the gun issue that I talked about, that is also part of these mass shootings we have constantly, is one that we very definitely want to—ought to address, because we are arming the very people who are sending that poison north.

But I do believe that Mexico needs to be pushed, or cajoled, or something. I’m not a foreign policy expert on this, but need—there needs to be some push to get Mexico to do a whole lot more than they are doing. You know, the traffickers have actually painted themselves into a corner, it seems to me. They got these enormous profits, much less risk and all, but they have—they rely on ingredients coming into a handful of ports. Now, it would seem to me, instead of covering the entire country—investigating entire country, all you have to do is really focus dramatically on these—on these ports. Two on the western side, in Manzanillo and Michoacán—Colima and Michoacán, but others as well, Mexico City Airport.

It does not seem to me to be a job that is, you know, impossible to do. I think the traffickers themselves have kind of, like, narrowed the places where they make their money. So it’s a complicated thing, about—to Vanda, on these kinds of things. I lived in Mexico, but it’s been a long time since I studied the foreign policy of it all. But I do believe that with the—we have never had—here’s the thing. We have never had with Mexico, a relationship in which—of equals, both working towards the same goal, which is the goal that both ought to be working towards, which was a suppression of these mafia groups.

I think the Italian—our experience with the Italian mob in the United States ought to show that we—that can be very effective, when it’s applied. We didn’t apply—under J. Edgar Hoover, we didn’t apply anything for fifty years. And then he dies, and then another ten years pass, and we have the RICO statutes. And pretty soon we apply those RICO statutes. And now the mob is—the Italian mob is a minor question, when it used to be its tentacles were very, very, very widespread. So I think that there’s a lot of opportunity here, in part, sadly, because so little has actually been tried between the countries we’re talking about.

ROBBINS: So questions, you all? You’re journalists. I’m sure you—bless you—I’m sure you all have a lot of questions. So please raise hands, put questions in the Q&A. And there’s a large group out there, so please jump in here. Because if not, I’m going to start being a professor and start calling on people randomly. (Laughter.) So we talk a little bit about the—sort of the psychology of decriminalization and how sort of the politics of drugs and how that’s affected the fentanyl, because these are very different sorts of drugs. Vanda, you want to talk a little bit about that, and how it’s playing out? And is it playing out in different states in a different way, and, you know, different—in different cities in a different way?

FELBAB-BROWN: And I’m sure that Sam will want to come in on the local dimension. So the answer is yes. It is playing differently across different localities, which is not surprising. It’s producing all kinds of surprising pushbacks. For example, the city of New York opened one safe injection site. This was deeply welcomed by the drug policy reform community, by the harm reduction communities. But it’s been opened in fairly low socioeconomic class neighborhood with extensive presence of people of color. And again, you would think, well, this is going to be welcomed because it is often the black community, for example, that has borne the brunt of repressive policies, attitudes toward arresting users that generated a lot of the spur for drug policy reform, that so disproportionately led to imprisonment of Black people for crack cocaine offenses, for example.

And yet, it is the local communities that do not want the safe injection site, that are complaining about the fact that there is little. That are people who suffer from substance use disorder very visibly. And it is the minority communities pushing on the police commissioner, pushing on the local district attorney’s office: We want the site out, even though the site is good. It’s good for people to have access to save injections and be able to be monitored. So, you know, this is showing some of the complexity of, again, how the reformer messages can be very simplistic, how the notion that only do the opposite of what we are doing is changing our progression—is being challenged by the opioid epidemic. And the implications are far more complex, far less uniform than was expected.

What is also different about the opioid epidemic is something that I touched on briefly before, and that is that it really affected much very different segments, very wide segments, and wide set of segments, of population. So if you think about other drugs, you will have kind of the cocaine elite, the very rich cocaine market. And then you will have kind of the crack cocaine again, affecting Black communities, for example. And you will have your standard entrance into recreational drugs is people who enter in their teens, and usually if they don’t have substance use disorder by the time they’re in their late twenties they will come out of it of their own, because they now are just part of the regularized world of being adult, or they will develop substance use disorder and we’ll have to contend with that. I am putting the cannabis market aside.

This is not what’s happening with opioids, and what didn’t happen with opioids. Because the opioid crisis started through a legal market, it was the legal commercial market that unleashed the biggest drug epidemic ever in history. Not the most legal one, fentanyl did the lethality, but the scale and scope was the legal commercial market. It affected very different types of people. So, yes, you would have your teenagers entering because they sought out recreational drugs and ended up at some point into use to opioids. But you would have also teenagers who would be prescribed opioids for a sprained ankle.

And you will have the grandmothers, the elderly, who would be prescribed two weeks’ worth of oxycontin for a break. A break in an elder age is a difficult—it’s a difficult injury. It’s very painful under all circumstances, but it’s very difficult for older people to keep—to bear up with this level of pain. So you will have your seventy-year-old grandmothers becoming rapidly addicted to prescription opioids, and everyone in between. And it did not concentrate in poor communities. It did not concentrate in communities of color. And so there is a lot of sentiment that the reason the U.S. abandoned its draconian anti-treatment, anti-harm reduction approaches was because this was now a problem of the white middle class also, not just of these marginalized communities who’ve not—who would not have a voice.

If you don’t have questions of me, eventually—

ROBBINS: No, I actually have six questions, which we’ll get to—

FELBAB-BROWN: OK, terrific. So I can offer some thoughts on AMLO and the Mexican policy, but let me make one comment. So I’ve been going to Mexico over the past twenty years. I haven’t lived there for ten years in a stretch at all, like Sam, but have been going there for extended periods. And I just came from five weeks of a research trip across Mexico. And one of the pernicious new developments, really bad development, is the opening of legal—well, is the opening of pharmacies in Mexico that look like your official pharmacy, that are labeled Farmacia, and that are very polished, brick and mortar buildings. This is not your dealer, or your cab—your typical Cancun cabbie telling you: I know how to get you coke.

This is very official-looking structures that are selling—publicly advertising anything from antibiotics, to anabolic steroids, to Cialis and Viagra. All of it should be the prescription and all of it should not be just accessible by you’re walking in and you’re buying yourself a bottle of—or a bag of antibiotics. But they’re also selling prescription opioids, or what they claim are prescription opioids, again, without prescription, in clear violation of Mexican laws, in clear violation of U.S. laws. And these drugs are showing to have either meth in them or fentanyl.

And this is very, very bad, because it, again, exposes wide set of people to—they clearly cater to Western tourists. A bottle costs, like, $85. But this is very bad because it exposes wide range of tourists. This is your cruise ship with sixty-seventy-year-old Germans coming to Cancun, or coming to Puerto Escondido, and now becoming exposed if they go in and buy, you know, presumably Percocet, and they’re in fact buying some combo with fentanyl.

ROBBINS: Wow. So, Sophia Bollag, can you—do you want to ask your question? And if you could identify yourself quickly. Oh, political reporter with the Sacramento Bee. I just got that from Irina. Sophia, do you want to ask your question? I can read it also.

Q: Can you hear me?

ROBBINS: Yep, absolutely.

Q: Great. And I’m actually with the San Francisco Chronicle. I used to work for the Bee.

But, Sam, I just wanted to ask, you had mentioned the role that you see jails and prisons playing in essentially the treatment of people who are addicted to fentanyl and other opioids. In California, lawmakers are looking at expanding essentially involuntary commitment in, like, residential treatment centers of people with mental illness, but also specifically drug users who have been deemed essentially unable to care for themselves. And I’m just curious to hear what you think about that policy proposal.

QUINONES: Well, you know, my discussion of jail is based on reporting that I’ve done in the Midwest, where you see a lot of—a good number of jails experimenting with new ways of doing jail. And, in part, it’s a response to the opioid epidemic and, in part, it’s a response to more recently fentanyl. So I’d have to see. I mean, I—talking about jail, not prison so much, OK? Jail is where people on the street have their first interface with the criminal justice system in jail. Jail is the crucial place where, it seems to me, this needs to take place. Because by the time you’ve done something serious enough to get sent to prison, which has to be pretty serious nowadays, you know, you’re very far along in your addiction. I think that jail is the issue, really, more than anything.

So I would be interested in seeing how this works. I do believe there has to be a role for civil commitment, because I do believe that these two drugs—all drugs of abuse do this, but these two drugs seem to do it so powerfully, and that is to squelch our instinct for self-preservation. And you can see this in the streets. You can see in San Francisco. You can see it in L.A. You can see it in various places, Vegas, and et cetera, all over the country. And what’s more, you find people saying, well, you know, I offered treatment, I offered housing, and say, no, I’m fine. People may have been doing this for years. I mean, I remember Skid Row in New York City in the 1970s when I was there as a kid. People were not—you know, were staying on the street instead of going into treatment.

But the drugs on the street now are just a different kind. And the prevalence and the potency are just so much more powerful that we need some place to put people to give them a fighting chance to develop the readiness for treatment, that they cannot develop while they are on the street. And you are finding, I think, increasingly, people, once they are separated from the drugs, once they’ve have had some time for their brains to heal, for their minds to clear, et cetera, then they become yes, no, I want this, right, yeah. But you just said three months ago when you were on the streets, you didn’t. Well, of course not. When you’re under the influence of these drugs that just are in your face constantly.

And the crucial thing is—with this stuff is that you need to give people a fighting chance, because otherwise meth is going to drive them mad, and fentanyl will kill them. There isn’t really a lot of long—we don’t have the luxury of time on this kind of stuff. And so jail, as a place where recovery can begin, but as a place also where you cannot leave when the dope insists that you do so, seems to me to be an approach adequate to the current situation on the streets. And I think that’s why it’s finding increasingly acceptance in different places around the country.

ROBBINS: Thank you. So I’m going to ask both of you to give shorter answers, only because we’re now very popular and we now we have lots of questions, which is—which is fabulous.

I’m going to—if Michael Goldberg and Stephanie Grace, if you don’t mind, I’m going to put your two questions together because they complement each other. Michael Goldberg asked: Much of the policy debate around the fentanyl crisis centers around federal and foreign policy. And how might state and local governments play a role on combating the fentanyl crisis? Obviously, residential commitment or jails is one example of that.

And then Stephanie Grace from the Orleans Advocate in New Orleans asked for specifics. Are there any local and state governments that have come up with promising strategies? Can you point to a few specific examples? I certainly know that as a reporter, I always love to find places that are actually succeeding that we might be able to pattern something on. Vanda, have you seen anything domestically that you found that a state or local government is doing that’s hopeful?

FELBAB-BROWN: So I really work much more on the supply foreign policy dimensions. I would suggest that folks who really want to get in-depth, in the weeds, speak with Sam. But also the RAND Corporation Drug Policy Center has really done some of the premier work on domestic policies, and they will have done evaluations at the local level. I would point to, again, issues, the sort of simplistic notion that decriminalization and/or only expanding availability of harm reduction approaches seems to be really backfiring in places like Seattle, in Oregon more broadly, in San Francisco. I spoke about the local reactions to the safe injection site in New York, although I actually am a strong supporter of safe injection sites, something that is still controversial and tangles with the federal level.

If we have time, I want to come in on the coerced introduction to treatment, so in prison or not. But if we have time, I want to add the angel and the devils are in lots of details. So this can be done really badly, or it can be done well. And—

QUINONES: Like everything. Like everything in this, you can do things. It’s all about—I’ve seen wonderful methadone clinics, and methadone clinics that act as hives of, you know. All of this, of course, is about how you do the details.

I did see one question that I wanted to get to, if I could. Tips for a student journalist at a college newspaper in a small town covering this issue. We know meth and homelessness are major issues in the town. I would say this, and this will, I think, lead you to more connection to places or are ideas that seem to be having some effect. And that is, it seems to me that the best sources are close—as close as you can get to the ground. For example, I do in jail and prison interviews all the time. Very, very important. For this story, I would say major sources of information are paramedics, ER docs and ER nurses, outreach workers who go into homeless encampments and whatnot, drug counselors, addicts themselves, obviously, recovering addicts, because frequently they have a clarity of mind and an ability to spend time and enunciate and articulate ideas that people who are strung out on the street don’t have.

I think once you get down into as close as you possibly can to the street—and that means also going to the jail and talking to people who are in the jail, or maybe talking to the—your drug court judge, or whatever you have in your town, these are all sources that are very—are not difficult to access. They are very, very important. And so if you’re struggling with ways of covering it in your town, I found too that when you talked with people on the ground, first of all, you’re up on the latest—they see things in real time. An ER doc, ER nurse, paramedic, they’re seeing it almost immediately as it hits your area. But also, it gives you an opportunity to see possibly what little things might be tried that might work.

So I would urge you, as a student journalist, to think about getting down as close as possible, and going to the jail, and asking for interviews there as well. It’s not hard to do. And it usually yields amazing results.

ROBBINS: Thanks. Is it Rachel—is it Mipro or Mipro—from the Kansas Reflector. Rachel, do you want to read your question quickly? And I think this’ll—

Q: Yeah, I would love to do it. It’s Mipro.

So this is going to be, like, a couple of questions wrapped into one. I mean, here in Kansas, our attorney general has tied this issue to illegal immigration. He’s saying, you know, we’ve got to crackdown on the southern border. And he’s also implemented, like, a law—a state law enforcement team to kind of try to crack down on this. So basically, my question is, is law enforcement seizure an effective way to prevent the spread? And then we’ve also heard a lot of China and Mexico role in this. And we’re hearing a lot of, usually Republican politicians, tie this sort of thing to illegal immigration rhetoric. Is there no in-house production of fentanyl? And how is this rhetoric part of the conversation? A lot of questions, sorry. (Laughs.)

ROBBINS: Vanda, this sounds like it’s one for you.

FELBAB-BROWN: Yeah, I just sat on my hearing yesterday that was all about this. So let me put some facts. And these are official U.S. government CBP facts. By the way, if you’re interested in this topic, I highly recommend watching the hearing. It was House Committee on Homeland Security and the hearing was very lengthy, a lot of details came out.

So more than 90 percent, or around 90 percent of all seizures occur in legal ports of entry. They are in—carried by predominantly U.S. citizens recruited by the Mexican cartels. And very frequently in U.S. license plates. The second large components still within that 90, it’s fentanyl being hidden in cargo. So in legal cargo, legal goods that are entering from Mexico. The number of migrants crossing the border, unauthorized migrants crossing the border between legal ports of entry carrying fentanyl, it’s a very, very small. It’s within the 10 percent category, but even that’s not a full number because some of the seizures are also occurring inland at points of entry, at vehicle checkpoints. So unauthorized migrants are not the primary or important carrier of fentanyl.

The second question was, do seizures matter? Seizures seek to do two things. They seek to limit the availability and they seek to boost prices. Seizures often do so very ineffectively. So, you know, in something like cocaine and heroin, the prices today are less than 20 percent of what they were in the 1980s, which will lead people in the drug policy community to say, see this isn’t effective. But this is only part of the answer. If you had no seizures, the price of both drugs would be far less than the 20 percent. So seizures and law enforcement make profits. This is what makes profits for criminal groups, but they still raise price. If you had no enforcement, then the price of a bag of cocaine would be exactly equivalent to the price of a bag of tea, and less for a bag of fentanyl.

So there is still—seizures and limiting supply is important. Directing it away from widely accessible places, like these pharmacies I was speaking about in Mexico or, for that matter, from us pharmacists and doctor over-prescribing the supply of legal opiates, this is still very important. It’s insufficient, but it’s very important.

What really needs to happen, and this is where there is this big hole in Mexico’s cooperation with the United States and in Mexico’s own law enforcement policy, is that in addition to seizures you want to be dismantling networks. You just don’t want to be shutting down a lab, because a lab is easy to recreate. But you want to be dismantling networks. And this is where Mexican action has essentially stopped after President López Obrador came to office.

QUINONES: Yeah, that’s right.

ROBBINS: So we—I’m going to put together all the same—we only have five more minutes—so I’m going to put together our remaining ones, which are all really good questions. Which is—well, Ryan Haas a question about the role of jails. You know, adopting this forced treatment approach. I want—Vanda wanted to comment about the—about the good and the bad of this. So I’m going to—Vanda, if you could quickly do that, then we’ll go back to Sam, and then we’ve got a few more questions. But you did want to comment about forced treatment, and both the good and the bad of it.

FELBAB-BROWN: So if prison simply to make people go cold turkey, is overwhelmingly ineffective. Even when people cannot source the drugs to which they are addicted in prisons, when they are released from prison, they will often end up very rapidly overdosing. And this is true not just from the United States. We see this from Saudi Arabia, Iran. We see this in China. We see this in Taiwan. If coerced treatment actually is meaningful treatment, then it can make a positive outcome.

So the greatest successes have come in projects like Project Hope, that would mandate that someone would be arrested or pulled over for driving under use, under influence, whether it be drugs or alcohol. And they would say, OK, you’re spending a night in prison. And next time we pull you over and you are still high, whether on drugs or on alcohol, you will spend five days—five nights or four nights in prison, escalating penalties. And people who were essentially controlled users, who had the ability to stop, we see dramatic decreases in their problematic behavior. And very strong success in alcohol and strong success even with other drugs.

Now you have a set of people who will simply be—have chronic deep disease. The coercive approach to them is far less—of limited success. And it might be that the coercive approach introduces them to some initial access to help, but a lot of other factors need to kick in for that help to be sustained. They will be chronically ill for most of their life.

ROBBINS: So, Sam, very quickly, Yomara Lopez, you want to ask your question, or shall I read it?

QUINONES: Can I say, I’ve read her question, and I don’t—I haven’t really investigated the Tenderloin sufficiently to know the answer to that. I’m sorry.

ROBBINS: OK. So Kate Walters, asks—I’ve got Siri talking back to me, it’s very confusing. Kate Walters asks: Can you expand a bit more on the role of harm reduction in addressing the current crisis? Other forms of harm reduction we should be thinking about? Sam, Vanda? And we only have two minutes, so quickly. (Laughter.) And if you don’t want to talk about that, you can talk about anything you want.

QUINONES: Let me talk about what Ryan was asking, because I think I want to make sure I get across that the reporting that I’ve done it has found in these—in these jails, first of all, that the pods that turn into—that transform into recovery pods are, you know, you opt in voluntarily. And then it’s all about recovery. So there’s no drugs in these recovery pods, even though there are drugs and the rest of the other parts of the jail. There are also social workers there who sign you up for Medicaid, so when you leave jail you are on Medicaid, which is very, very important.

Also, medically assisted treatment. It could be methadone. It could be Suboxone. It could be Vivitrol, whatever it happens to be. You also have in the jail I was writing about in my book, The Least of Us, in Kenton County, you have—extraordinarily important in all this is not just what goes on in jail but that there be a continuum of care that continues after release. Obviously, if it’s only in jail that you’re working, that when you leave it’s going to—you will very quickly return to using. And so to me this is an idea that I had not considered. I don’t think, as I’ve spoken about it around the country, I’m not seeing people actually ever having thought about it.

And it allows us to turn a negative, which is generally jail, although a lot of people, regardless of what’s available to them in jail use jail as a place to get clean. And I have talked to many people who have done that. It’s still not a place where we really can make the best of it. And you’re so you’re finding this rethinking of jail, all with the idea of what happens to this person when that person leaves the jail gates. And that is a radical idea too. It’s never really been part of what we—what we thought of as jail. And so my suggestion to folks is you might want to check in with some of the jails that are trying this.

Kenton County, Kentucky is one, and Covington, Kentucky. Columbus, Ohio has a new jail that’s just opening now. I think probably be fully—it'll be full by the time—by September. Remarkable, remarkable jail. Remarkable jail. That’s a state-of-the-art jail for the twenty-first century, with addiction being a major focus of what you’re seeing there. So I would say we don’t have a lot of time to talk about this. I would also just say that this is not the jail that you know, from the last fifty years. This is a very different way of thinking about jail, with different people working in jail. And to me, it seems appropriate—from my reporting—seems appropriate to the time we’re living in right now.

ROBBINS: I want to thank you both so much. We’re going to share both Sam and Vanda’s writing. Vanda has a fabulous piece in Foreign Affairs that talks about what we didn’t get to, which is the use of sanctions and other ways of pressuring governments, and working with Mexico and China potentially to perhaps get a better outcome here. Sam has an Atlantic piece. He’s written op-eds in the in the Washington Post. So we’re going to share some of their writing. We’ll also put in a link to the hearing, which I assume is online already from yesterday. And I’m going to turn it back to Irina. Thank you both so much. I learned an enormous amount. So thank you.

FASKIANOS: Yes, thank you all. And you can also follow Vanda on Twitter at @vfelbabbrown, and Sam at—on Twitter also—at @samquinones7. And as always, we encourage you to visit CFR.org, ForeignAffairs.com, and ThinkGlobalHealth.org for the latest developments and analysis on international trends and how they’re affecting the United States. And again, we encourage you to share your suggestions for future webinars. You can email us at [email protected]. So, again, thank you all for today’s really rich conversation. We appreciate it.

QUINONES: Thank you.

ROBBINS: Thanks, guys.

FASKIANOS: Thank you. Welcome to the Council on Foreign Relations Local Journalists Webinar. I’m Irina Faskianos, vice president for the National Program and Outreach here at CFR.

CFR is an independent and nonpartisan membership organization. think tank, publisher, and educational institution focusing on U.S. foreign policy. CFR is also the publisher of Foreign Affairs magazine. As always, CFR takes no institutional positions on matters of policy. This webinar is part of CFR’s Local Journalists Initiative created to help you draw connections between the local issues you cover and national and international dynamics. Our programming puts you in touch with CFR resources and expertise on international issues and provides a forum for sharing best practices.

We appreciate your taking the time to be with us today for this discussion. The webinar is on the record. The video and transcript will be posted on our website after the fact at CFR.org/local journalists,

We are pleased to have Vanda Felbab-Brown and Sam Quinones to lead today’s discussion with Carla Ann Robbins. Vanda Felbab-Brown is a senior fellow in the Strobe Talbott Center for Security, Strategy, and Technology in the Foreign Policy Program at Brookings Institution. She’s an expert on international and internal conflicts and nontraditional security threats, including organized crime and illicit economies. And she serves as co-director of the Brookings research project The Opioid Crisis in America: Domestic and International dimensions,” which publishes a series of papers to address opioid addiction and weaknesses in U.S. drug policy and health systems.

Sam Quinones is a freelance journalist, author, and public speaker. He lived in Mexico for ten years as a freelance reporter covering Mexican politics, immigration, and drug trafficking. He also spent ten years as a reporter for the L.A. Times. And most recently, he has authored two books on the opioid epidemic Dreamland—The True Tale of America’s Opioid Epidemic, in 2015, and The Least of Us: True Tales of America and Hope in the Time Fentanyl and Meth, in 2021.

And our host is Carla Ann Robbins. She’s a senior fellow at CFR. She’s the faculty director of the Master of International Affairs Program and clinical professor of national security studies at Baruch College’s Marxe School of Public and International Affairs. Previously, she was deputy editorial page editor at the New York Times and chief diplomatic correspondent at the Wall Street Journal. I’m going to turn it over to Carla to lead the conversation. And then we’ll go to all of you for your comments and questions. So, Carla, over to you.

ROBBINS: Irina, thank you so much. And, Vanda and Sam, thank you so much for doing this today.

Sam, can we start with you and with some basics? What’s fentanyl? Is it more dangerous and addictive than other opiates? And why is this epidemic different from other—sorry—other drug epidemics, or is it?

QUINONES: Well, fentanyl is actually a magnificent drug and very important to keep that in mind. I’ve had something myself and, in the surgical setting, it has revolutionized surgery. Made it far easier to do certain surgeries, and been a workhorse drug, particularly in cardiac surgery. I had a heart attack six years ago and was given fentanyl then. So it’s very important to keep in mind that this is a workhorse, revolutionary drug that really has done a lot of good for humankind.

Of course, when this—what makes it a great drug, and aesthetically, is also what makes it a problem when it’s controlled by the underworld. And that is, first thing, it’s enormously potent and much more potent than heroin. It’s an opioid, although it’s made, not grown from the—or taken from the opium poppy. It’s made with chemicals. It’s a synthetic drug—fully synthetic drug. And the other thing about it is—that makes it a wonderful drug surgically—is that it takes you in and out of anesthesia very, very quickly.

That’s exactly what makes it a disaster on the street, because then—for two reasons. One, users tend to have to always be using fentanyl all day long, because of that. And also, traffickers see it as a magnificent addendum to their offerings, and have added it to cocaine, and meth, and marijuana. And what they frequently end up doing, killing a few people—killing some people along the way, but also creating full-time multi-purchase daily addicts from people who used to be, at one point, may be occasional cocaine users. And that is—a lot of this was just simply the function of the amount of fentanyl that’s now coming in, primarily from Mexico, across the United States.

So really, we’re seeing now fentanyl cover the United States. It was not the case, say, in 2014-15, those years. You saw it mainly confined to the areas where the opioid epidemic, that I wrote about in my Dreamland book, was really the issue. Then the Mexicans really got involved big time, and more and more people learned how to make it, and the ingredients to make it were—became very plentiful, imported in from China. And you began to see an explosion of supply. And so you saw going from the Midwest, to both coasts, and across the country. So now you find fentanyl all over the United States, along with methamphetamine, another synthetic drug that is made in similar kind of quantities.

And that’s also what makes this a very different situation. We have never seen two drugs—I really pair them together; it’s hard to separate them, in my opinion—two drugs of such potency, such prevalence, such low price nationwide, and was such devastating effects. Of course, fentanyl is a highly deadly drug when used in this way. Methamphetamine, in the intense purity that it’s coming in from Mexico, the intense potency it’s coming in from Mexico, has really shown itself to be transformative in, particularly, creating very rapid-onset symptoms of schizophrenia, and very often homelessness, and this kind of thing.

And so that’s a very brief summary of these two drugs, because I have trouble separating them, really. I think they’re all kind of part of the same story. But certainly, fentanyl is the most deadly drug we’ve ever seen on our streets, particularly given the supplies and the prevalence that we’re seeing it now, nationwide.

ROBBINS: So can you be a—I don’t mean you personally—but can one be a casual fentanyl user? Or is it the sort of thing that you take and you very quickly get addicted?

QUINONES: With the supplies that we’re seeing now I think it’s very difficult to argue that you could do that. I think that the—I mean, I’ve known—

ROBBINS: But I mean, just chemically. I mean, biologically.

QUINONES: I think it’s such a potent drug that it’s very difficult to achieve that. There’s very—I mean, if you have the supply reduced and you can’t get access to it, then perhaps. But I believe that with the supplies that we have today on the street, it’s very difficult to be a functioning fentanyl user. I’m sure there are some, but I don’t think that’s the norm. The other truth is, I think, very clearly on the streets of America today, that there is no such thing as a long-term, fentanyl addict. They all seem to die. Now, if you looked at heroin, I’ve known heroin addicts that used heroin for twenty, thirty, forty years, and a very—and, you know, they don’t have a great life, but you know, they’re not dead. I just don’t see that with fentanyl, given, again, the supplies that we’re seeing coming in from Mexico now.

ROBBINS: So, thanks. Vanda, can we talk about the international component of this? Sam mentioned it coming from Mexico, but most of it originates—either that, or the precursor chemicals—originate in China. Can you talk about the supply chain and the particular challenges of trying to stop something that, I suppose, the precursors are dual use chemicals?

FELBAB-BROWN: I will. Let me just add a few comments to expand on Sam’s points and your original question, Carla. So fentanyl is a very dangerous drug. It’s at least fifty times as potent as heroin. And other varieties and analogs of fentanyl-type drugs can be many more times as potent. Carfentanil is at least a hundred times as potent. That has two effects, it induces substance use disorder, popularly known as addiction, extremely rapidly with very limited exposure.

It also means that the lethality, the chance of overdose, is very high, particularly as many users who are sourcing any kind of opioids—whether it’s oxycontin or whether they’re sourcing completely other drugs such as cocaine, a very different type of drugs—these days, not just in the United States but also in Canada and in Mexico, often end up buying a mixture that has fentanyl. So fentanyl can be used as an adulterant in a whole variety of drugs.

Fentanyl is enormously attractive from the perspective of suppliers. And this is indeed the most lethal epidemic ever in human history. And we are heading into much greater lethality rates as fentanyl is spreading, will spread beyond North America. But already as it is, it’s the most lethal epidemic ever in human history, affecting wide segments of population. Not just your typical entry user into recreational drugs, but causing in the United States four times, five times as high of lethality in people over sixty-five. Something we have never seen with any other drug.

But even though it’s this dangerous, it’s enormously attractive for traffickers because of the potency per rate ratio, which makes it very easy to source it. And here’s where I’m coming to the supply chain. Very small amounts of precursor chemicals are needed to produce fentanyl. Just a small fraction of the chemicals needed for heroin or cocaine. And the same also is true on the finished product. So the rule of thumb is that it takes about ten trailer trucks of cocaine or heroin to supply the U.S. drug market for a year. Well, it will take one trailer truck of fentanyl, on tenth or less than one tenth.

Now, obviously, no trafficking organization, certainly not the Sinaloa Cartel and Cártel de Jalisco Nueva Generación, are going to send one full trailer truck of cocaine. They will disperse the amounts. But the detection problem from precursor source all the way to retail are enormously grown. And this then is a drug that has been pushed to users not as a result of demand. This epidemic is driven by supply, because it’s so convenient for traffickers. And this is part and parcel of the synthetic drug revolution that is sweeping global drug markets. It’s sweeping East Asia. It’s emerging in Africa. It’s causing countries like Afghanistan with all its poppy, at least until the Taliban ban and its enforcement a year ago, to be producing meth.

So what does the supply look like? Precursor chemicals originate predominantly in two places, India and China. The vast majority still in China. And today, just like with methamphetamine, about which Sam spoke, the precursors are mostly what is called pre-precursors. So very basic chemicals that have enormous use in any kind of legal chemistry, agricultural products, pharmaceutical products. As a result, they are enormously difficult to control. Many of them, the vast majority of the pre-precursors available today, are not scheduled. That means there are minimal controls.

Nonetheless, it’s also very obvious that Chinese suppliers knowingly, directly, purposefully sell to Mexican criminal groups. That they don’t sell to a legitimate outlet not knowing that they were somehow diverted from them to the Sinaloa Cartel. There is knowing complicity. The Mexican groups then—the two predominant, Sinaloa and Jalisco, control the production—more or less have a duopoly on the production in Mexico. Despite the fact that President Lopez Obrador says there is no fentanyl produced in Mexico, they synthesize fentanyl in Mexico.

And then they smuggle it into United States, whether in its highly concentrated form or various adulterated forms. Sometimes the mixing into other drugs takes place in the U.S. Other times, fake oxycodone pills which contain fentanyl are sent from Mexico to the United States. The latest development is first—or early attempts, is the better way to phrase it—especially by Sinaloa Cartel—to push production to other areas like, Guatemala and Colombia.

ROBBINS: So—

FELBAB-BROWN: And my opening statement here is—

ROBBINS: Please, yes.

FELBAB-BROWN: Despite the fact that the supply chain is still very concentrated and clear, you know, it’s mostly China-Mexico-United States. That is some role of India and that can grow and you can have other countries that become sources of pre-precursors, it’s still a fairly straightforward line, there, unfortunately, is no meaningful cooperation between China and United States and between Mexico and the United States. In the first place, the relationship was always very weak, China-U.S., but completely collapsed as a result of the geostrategic tensions. And in the case of Mexico, the counternarcotics cooperation became completely eviscerated by the López Obrador administration.

ROBBINS: So I’m going to want to get more into those two relationships and what policy could possibly do, but wanted to go back a little bit about this notion of supply and demand and push and pull. Because, you know, for the longest time people who said that, you know, the number-one way to control a drug is for treatment. And is this different? And are—and, first of all, is the Biden administration doing a better job on treatment programs? Or is this just going to be overwhelmed because just—there’s just so much supply out there? Is this really something that’s got to be mainly a criminal or geostrategic and criminal problem to be solved that way? And, Sam, first over to you on that.

QUINONES: Well, I would very much agree with Vanda on this. This is a case of supply creating demand. I think I wrote about it in my book, and then a story recently for the Atlantic. I absolutely think that’s what the evidence shows, and my reporting shows as well. What I think it then requires—as they say on the street, fentanyl changes everything. I would say the same thing is true of methamphetamine. There’s very little about the drug situation today that bears any kind of resemblance to the plant-based drug problems that we had, you know, fifteen, twenty years ago, or what have you.

And so I do believe that, as Vanda said, that—well, first of all, that there is almost no collaboration or cooperation between the governments. She mentioned ours, Mexico, China, which is a real problem. We also have a problem, I think, in our country with the lifting of the ban on the commercial sale of assault weapons. And I think a lot of those assault weapons now are going down to Mexico, where they serve to ensure the impunity of a lot of the groups, as well as foment the violence that’s been going on down there since about 2005. Our ban ended in 2004, and the cartel wars in Mexico, I think, really begin to take root in in 2005. And I leave that to other people, whether they think that’s a coincidence or not. But I think that’s what’s going on.

I do believe that at the local level we have also, in various parts of the country, tried to apply policies—counties, cities, public health-type policies that that may have made sense in another era, and I don’t believe they make sense in a time now where the least little exposure to a drug means you very likely could be—could die. And I think the turning away from law enforcement has been a big, big mistake. The criminalization of sale of fentanyl, for example.

Anything containing fentanyl in many parts—in certain parts of the country, anyway, you find that to be almost a—basically a misdemeanor, even though selling fentanyl—I mean, selling something that contains fentanyl is like shooting a gun into a crowd. You know, you’re going to hurt somebody, you’re probably going to kill somebody. Yet we still have these ideas of how to approach this that were conceived in another era. And I think decriminalizing this stuff—I also—is part of that.

I think that another thing that I have been focusing on, simply because I don’t see anybody else doing it, and I find that my reporting has been—I’ve been very interested in this topic. And that is how, in an age of fentanyl and meth, it makes jail an essential element of our approach to this. And many parts of the country, jail is being rethought so it’s actually a recovery center, but you just can’t leave. And that’s the crucial thing about jail. And in a time when you’re on—when you’re—people are addicted to fentanyl and meth, drugs that are dominating their brain chemistry so totally that they won’t leave the street, they’re not—they’re never going to be ready for treatment, the way we’ve traditionally conceived it.

They need to be off the street, away from the drugs, and then they have a chance—they have a fighting chance to develop readiness. That’s what you’re finding when people are in these jails. And there are some around the country that are doing this. As I said, it’s a very interesting thing to watch. And so I think that this is—you know, these are—this is part of what these two drugs are changing in the United States.

I do believe, having lived in Mexico ten years, wrote two books about the country, that a deeper collaboration with Mexico is absolutely essential. I also believe that the current president of Mexico is, I’ll try to find a charitable way of putting it, but not up to the job—(laughter)—on this, or not up to recognizing what the issues are and the implications are of all that he’s facing.

ROBBINS: Vanda, you mentioned—and, Sam, thank you for that. And I’m sure you want to have some comment as well about domestic and local policy about this. But can we talk a bit about the Chinese before we turn this over? Why does the Chinese government enable this? I understand that why they might not want to make us happy, because we have a rather strained relationship with them, as we’re cutting off their supply of advanced chips and lots of other competition going on there. But is it that they don’t—you know, they don’t have a problem at home? I mean, their neighbors have problems and I’ve been criticizing them about it. Is it that there are high ranking Chinese officials who are in the business and so they have a corruption interest in it? I mean, what is the game for the Chinese?

FELBAB-BROWN: Yeah. I’ll definitely speak about China. And there’s a lot to unpack in China’s role and/or complicity. And I’ll come to that. Is it complicity? What is China’s role? But let me little bit speak about demand and, again, just complement some of the things that Sam said.

So, look, demand reduction, which consists of treatment and prevention, is absolutely essential. It is what needs to underpin any kind of response to dealing with any drugs. That is true also about synthetic drugs like opioids, like synthetic opioids, like fentanyl and methamphetamine. There is also a significant role for what’s called harm reduction measures. But they are insufficient in and of themselves.

And this epidemic, I think, very potently drives home two messages: The notion that the drugs are problematic only because they are illegal, that prohibition is the source of all evil, is being fundamentally challenged, in my view debunked, by what’s happening with the fentanyl and synthetics opioid epidemic. And for that matter, even with meth. (Laughs.) But also that harm reduction measures are sufficient.

Now, there are fundamental differences between meth and between opioids like fentanyl. So the one good news in the fentanyl epidemic has been that there are quite effective both harm reduction and treatment measures for opioids. You have the possibility of methadone replacement—very effective strategy. And you have overdose medication—Buprenorphine in popular parlance the brand name Narcan—that has reversed lethal overdose.

If we haven’t had Narcan, the amount of—the actual amount of overdose is about five times higher than the amount of death. So last year, we had about 107,000 deaths in the United States. The actual number of overdoses was five times that number, almost 600,000, 550,000. But Narcan and its availability have saved the lives, or reversed the overdose. That doesn’t mean that someone who had an overdose and received Narcan will be just fully fine functional, as if nothing happened. People can carry long term morbidity effects.

Methamphetamine is different. We don’t have overdose—although overdose is not so much an issue, even super-potent methadone. We don’t have the same replacement drugs. There is no equivalent to methadone in the meth space. And meth, especially in the highly—super-potent Mexican meth that Sam spoke about, creates very rapidly, very bad morbidity effects. So not only does it create addiction or substance use disorder, it also creates quite rapid, very difficult morbidity effects. The whole body is physically very affected. So the harm reduction measures we have for opioids we don’t have.

Now the story gets more complicated. And that’s the introduction of xylazine tranquilizer into the U.S. drug market, including into fentanyl. Xylazine can eviscerate the effects of Narcan. And it also now complicates the morbidity picture, not the mortality but the morbidity picture, of opioids. It makes opioids have very high morbidity effects, such as, you know, people—the necrotic tissue, with these horrible images that you’re starting to see.

There is—and one important dimension of it is—so you asked, you know, is the Biden administration doing enough? There has been significant progress in U.S. policy on attitudes towards treatment and harm reduction. It started already during the Trump administration, not because of the White House and the wisdom of the Trump administration, but because state and localities started piloting, experimenting with measures such as safe needle exchange, safe injection sites, and the availability of Narcan. So at the local level, already during the Trump era there was a break with the doctrinaire, rigid, absolutely no harm reduction measures typical of U.S. policy.

The Obama administration before significantly helped treatment because of the way that it changed and demanded mandatory access to various public health measures that often made it impossible for people with substance use disorder to access the medical system. And in the Biden administration, those trends have just continued. The Biden administration very explicitly embraced these public health responses.

So much so that one would even argue that we found ourselves in a paradoxical situation that until maybe half a year, three quarters of a year ago, most of U.S. policy toward fentanyl was not on the supply side, was very soft approach—a very soft approach both with AMLO and with China on this specific issue. There have been lots of highly contentious relationship with China. But it also showed how limited this response is. And I often point people to the fact that Vancouver, British Columbia have some of the most robustly funded and most expensive harm reduction measures of any locality in the world. Yet their opioid overdose is on par with West Virginia, one of the worst affected U.S. localities.

So let me come to China. So yesterday, I was doing a hearing and some of the Republican witnesses, some of my fellow witnesses, were making the comment that China is on purpose poisoning the United States. This is a form of asymmetric warfare, a strategy to kill off as many Americans as possible. And I don’t think that anyone can make the statement unless they have access to, you know, wiretap communications from the Politburo and Xi Jinping to, you know, top Chinese decision makers. China nonetheless, I have argued and showed in my research, very strongly subordinates all forms of law enforcement cooperation to the geostrategic relationship.

And this is not true just about the U.S. It’s its attitude toward other countries, from Australia to Vietnam to Cambodia to, you know, Thailand—pick your country. China extents law enforcement and counternarcotics cooperation when it seeks to court the country or when in hopes it will generate strategic payoffs. And when those strategic payoffs don’t materialize, and they have not during the Trump administration or during the Biden administration, China withdraws from the cooperation.

Now here, we need to separate the drugs. China has enormous problems with meth use. But even despite the fact that China has enormous problems with meth use, and the Chinese Triads are the principal dominant suppliers of meth across the Asia-Pacific region, China has also very complex relationship with the Triads. Chinese government official use the Triads for a whole variety of unofficial services. The Triads act as extralegal enforcers, they oil corruption with government officials in other countries. There is a relationship, not one of command but one of mediation, one of management.

Nonetheless, China has not had a problem with synthetic opioids. It has a heroin problem. Its heroin is supplied out of Afghanistan and, most importantly, out of Myanmar. But it hasn’t had a problem with synthetic opioids. And so China’s formal posture tends to be: We cannot control precursors because they’re not scheduled. And by the way, the United States, this is your problem. It’s your decadent society. It’s your evil pharmaceutical companies—which are, indeed, evil in the way they unleashed the opioid epidemic. (Laughter.) It’s your problem. It’s not ours. And to the extent that we have extended cooperation, like scheduling the fentanyl-class type of drugs in 2019, we did it as this grand humanitarian gesture toward you.

ROBBINS: So I want to turn it over—and this is hugely helpful. I want to turn it over to the group. And, please, you know, get ready with your questions, either raising your hands or putting them in into the Q&A, and we’ll call on you. But, Sam, really quickly, you talked about, you know, disappointment with AMLO. You talked about—but you’ve also written about the possibility of much greater cooperation between Biden and the current Mexican president. How does, you know, we’ve heard a lot of the things that the Vanda is saying about the Chinese perception of the United States, we’ve heard this from the Mexicans in the past as well. It’s your problem. It’s your consumption issue. It’s, you know, not—and then you add on to the fact that we are a major supplier of guns. I mean, how does this current government in Mexico see it? Is it a corruption issue? And, you know, you have to get inside their psychology before you can imagine what levers to pull to try to get better cooperation.

QUINONES: Right. It seems to me that there is a combination of blithe disregard, unwillingness to actually do much more than control immigration flows for the United States. Part of this, I think, has to do with the leftist history of Andrés Manuel López Obrador. Also I would say, when I was in Mexico I covered him. He was mayor, he was Senator. At the time he seemed a very coherent, articulate member of the left, and was able to enunciate and articulate strategies that I thought were, you know—you know, he did that well. I would say, it does not seem that he does that anymore.

He seems, in fact, almost, again, trying to be charitable, but, you know, it does not seem like he is in control of his full faculties. And I think that is part of the problem. His parent—I won’t say obedience, but certainly his collaboration with the military in ways that that make me question the reasons behind it are strange. And so, you know, I would say that we certainly have a lot on our side to question. And I would say the gun issue that I talked about, that is also part of these mass shootings we have constantly, is one that we very definitely want to—ought to address, because we are arming the very people who are sending that poison north.

But I do believe that Mexico needs to be pushed, or cajoled, or something. I’m not a foreign policy expert on this, but need—there needs to be some push to get Mexico to do a whole lot more than they are doing. You know, the traffickers have actually painted themselves into a corner, it seems to me. They got these enormous profits, much less risk and all, but they have—they rely on ingredients coming into a handful of ports. Now, it would seem to me, instead of covering the entire country—investigating entire country, all you have to do is really focus dramatically on these—on these ports. Two on the western side, in Manzanillo and Michoacán—Colima and Michoacán, but others as well, Mexico City Airport.

It does not seem to me to be a job that is, you know, impossible to do. I think the traffickers themselves have kind of, like, narrowed the places where they make their money. So it’s a complicated thing, about—to Vanda, on these kinds of things. I lived in Mexico, but it’s been a long time since I studied the foreign policy of it all. But I do believe that with the—we have never had—here’s the thing. We have never had with Mexico, a relationship in which—of equals, both working towards the same goal, which is the goal that both ought to be working towards, which was a suppression of these mafia groups.

I think the Italian—our experience with the Italian mob in the United States ought to show that we—that can be very effective, when it’s applied. We didn’t apply—under J. Edgar Hoover, we didn’t apply anything for fifty years. And then he dies, and then another ten years pass, and we have the RICO statutes. And pretty soon we apply those RICO statutes. And now the mob is—the Italian mob is a minor question, when it used to be its tentacles were very, very, very widespread. So I think that there’s a lot of opportunity here, in part, sadly, because so little has actually been tried between the countries we’re talking about.

ROBBINS: So questions, you all? You’re journalists. I’m sure you—bless you—I’m sure you all have a lot of questions. So please raise hands, put questions in the Q&A. And there’s a large group out there, so please jump in here. Because if not, I’m going to start being a professor and start calling on people randomly. (Laughter.) So we talk a little bit about the—sort of the psychology of decriminalization and how sort of the politics of drugs and how that’s affected the fentanyl, because these are very different sorts of drugs. Vanda, you want to talk a little bit about that, and how it’s playing out? And is it playing out in different states in a different way, and, you know, different—in different cities in a different way?

FELBAB-BROWN: And I’m sure that Sam will want to come in on the local dimension. So the answer is yes. It is playing differently across different localities, which is not surprising. It’s producing all kinds of surprising pushbacks. For example, the city of New York opened one safe injection site. This was deeply welcomed by the drug policy reform community, by the harm reduction communities. But it’s been opened in fairly low socioeconomic class neighborhood with extensive presence of people of color. And again, you would think, well, this is going to be welcomed because it is often the black community, for example, that has borne the brunt of repressive policies, attitudes toward arresting users that generated a lot of the spur for drug policy reform, that so disproportionately led to imprisonment of Black people for crack cocaine offenses, for example.

And yet, it is the local communities that do not want the safe injection site, that are complaining about the fact that there is little. That are people who suffer from substance use disorder very visibly. And it is the minority communities pushing on the police commissioner, pushing on the local district attorney’s office: We want the site out, even though the site is good. It’s good for people to have access to save injections and be able to be monitored. So, you know, this is showing some of the complexity of, again, how the reformer messages can be very simplistic, how the notion that only do the opposite of what we are doing is changing our progression—is being challenged by the opioid epidemic. And the implications are far more complex, far less uniform than was expected.

What is also different about the opioid epidemic is something that I touched on briefly before, and that is that it really affected much very different segments, very wide segments, and wide set of segments, of population. So if you think about other drugs, you will have kind of the cocaine elite, the very rich cocaine market. And then you will have kind of the crack cocaine again, affecting Black communities, for example. And you will have your standard entrance into recreational drugs is people who enter in their teens, and usually if they don’t have substance use disorder by the time they’re in their late twenties they will come out of it of their own, because they now are just part of the regularized world of being adult, or they will develop substance use disorder and we’ll have to contend with that. I am putting the cannabis market aside.

This is not what’s happening with opioids, and what didn’t happen with opioids. Because the opioid crisis started through a legal market, it was the legal commercial market that unleashed the biggest drug epidemic ever in history. Not the most legal one, fentanyl did the lethality, but the scale and scope was the legal commercial market. It affected very different types of people. So, yes, you would have your teenagers entering because they sought out recreational drugs and ended up at some point into use to opioids. But you would have also teenagers who would be prescribed opioids for a sprained ankle.

And you will have the grandmothers, the elderly, who would be prescribed two weeks’ worth of oxycontin for a break. A break in an elder age is a difficult—it’s a difficult injury. It’s very painful under all circumstances, but it’s very difficult for older people to keep—to bear up with this level of pain. So you will have your seventy-year-old grandmothers becoming rapidly addicted to prescription opioids, and everyone in between. And it did not concentrate in poor communities. It did not concentrate in communities of color. And so there is a lot of sentiment that the reason the U.S. abandoned its draconian anti-treatment, anti-harm reduction approaches was because this was now a problem of the white middle class also, not just of these marginalized communities who’ve not—who would not have a voice.

If you don’t have questions of me, eventually—

ROBBINS: No, I actually have six questions, which we’ll get to—

FELBAB-BROWN: OK, terrific. So I can offer some thoughts on AMLO and the Mexican policy, but let me make one comment. So I’ve been going to Mexico over the past twenty years. I haven’t lived there for ten years in a stretch at all, like Sam, but have been going there for extended periods. And I just came from five weeks of a research trip across Mexico. And one of the pernicious new developments, really bad development, is the opening of legal—well, is the opening of pharmacies in Mexico that look like your official pharmacy, that are labeled Farmacia, and that are very polished, brick and mortar buildings. This is not your dealer, or your cab—your typical Cancun cabbie telling you: I know how to get you coke.

This is very official-looking structures that are selling—publicly advertising anything from antibiotics, to anabolic steroids, to Cialis and Viagra. All of it should be the prescription and all of it should not be just accessible by you’re walking in and you’re buying yourself a bottle of—or a bag of antibiotics. But they’re also selling prescription opioids, or what they claim are prescription opioids, again, without prescription, in clear violation of Mexican laws, in clear violation of U.S. laws. And these drugs are showing to have either meth in them or fentanyl.

And this is very, very bad, because it, again, exposes wide set of people to—they clearly cater to Western tourists. A bottle costs, like, $85. But this is very bad because it exposes wide range of tourists. This is your cruise ship with sixty-seventy-year-old Germans coming to Cancun, or coming to Puerto Escondido, and now becoming exposed if they go in and buy, you know, presumably Percocet, and they’re in fact buying some combo with fentanyl.

ROBBINS: Wow. So, Sophia Bollag, can you—do you want to ask your question? And if you could identify yourself quickly. Oh, political reporter with the Sacramento Bee. I just got that from Irina. Sophia, do you want to ask your question? I can read it also.

Q: Can you hear me?

ROBBINS: Yep, absolutely.

Q: Great. And I’m actually with the San Francisco Chronicle. I used to work for the Bee.

But, Sam, I just wanted to ask, you had mentioned the role that you see jails and prisons playing in essentially the treatment of people who are addicted to fentanyl and other opioids. In California, lawmakers are looking at expanding essentially involuntary commitment in, like, residential treatment centers of people with mental illness, but also specifically drug users who have been deemed essentially unable to care for themselves. And I’m just curious to hear what you think about that policy proposal.

QUINONES: Well, you know, my discussion of jail is based on reporting that I’ve done in the Midwest, where you see a lot of—a good number of jails experimenting with new ways of doing jail. And, in part, it’s a response to the opioid epidemic and, in part, it’s a response to more recently fentanyl. So I’d have to see. I mean, I—talking about jail, not prison so much, OK? Jail is where people on the street have their first interface with the criminal justice system in jail. Jail is the crucial place where, it seems to me, this needs to take place. Because by the time you’ve done something serious enough to get sent to prison, which has to be pretty serious nowadays, you know, you’re very far along in your addiction. I think that jail is the issue, really, more than anything.

So I would be interested in seeing how this works. I do believe there has to be a role for civil commitment, because I do believe that these two drugs—all drugs of abuse do this, but these two drugs seem to do it so powerfully, and that is to squelch our instinct for self-preservation. And you can see this in the streets. You can see in San Francisco. You can see it in L.A. You can see it in various places, Vegas, and et cetera, all over the country. And what’s more, you find people saying, well, you know, I offered treatment, I offered housing, and say, no, I’m fine. People may have been doing this for years. I mean, I remember Skid Row in New York City in the 1970s when I was there as a kid. People were not—you know, were staying on the street instead of going into treatment.

But the drugs on the street now are just a different kind. And the prevalence and the potency are just so much more powerful that we need some place to put people to give them a fighting chance to develop the readiness for treatment, that they cannot develop while they are on the street. And you are finding, I think, increasingly, people, once they are separated from the drugs, once they’ve have had some time for their brains to heal, for their minds to clear, et cetera, then they become yes, no, I want this, right, yeah. But you just said three months ago when you were on the streets, you didn’t. Well, of course not. When you’re under the influence of these drugs that just are in your face constantly.

And the crucial thing is—with this stuff is that you need to give people a fighting chance, because otherwise meth is going to drive them mad, and fentanyl will kill them. There isn’t really a lot of long—we don’t have the luxury of time on this kind of stuff. And so jail, as a place where recovery can begin, but as a place also where you cannot leave when the dope insists that you do so, seems to me to be an approach adequate to the current situation on the streets. And I think that’s why it’s finding increasingly acceptance in different places around the country.

ROBBINS: Thank you. So I’m going to ask both of you to give shorter answers, only because we’re now very popular and we now we have lots of questions, which is—which is fabulous.

I’m going to—if Michael Goldberg and Stephanie Grace, if you don’t mind, I’m going to put your two questions together because they complement each other. Michael Goldberg asked: Much of the policy debate around the fentanyl crisis centers around federal and foreign policy. And how might state and local governments play a role on combating the fentanyl crisis? Obviously, residential commitment or jails is one example of that.

And then Stephanie Grace from the Orleans Advocate in New Orleans asked for specifics. Are there any local and state governments that have come up with promising strategies? Can you point to a few specific examples? I certainly know that as a reporter, I always love to find places that are actually succeeding that we might be able to pattern something on. Vanda, have you seen anything domestically that you found that a state or local government is doing that’s hopeful?

FELBAB-BROWN: So I really work much more on the supply foreign policy dimensions. I would suggest that folks who really want to get in-depth, in the weeds, speak with Sam. But also the RAND Corporation Drug Policy Center has really done some of the premier work on domestic policies, and they will have done evaluations at the local level. I would point to, again, issues, the sort of simplistic notion that decriminalization and/or only expanding availability of harm reduction approaches seems to be really backfiring in places like Seattle, in Oregon more broadly, in San Francisco. I spoke about the local reactions to the safe injection site in New York, although I actually am a strong supporter of safe injection sites, something that is still controversial and tangles with the federal level.

If we have time, I want to come in on the coerced introduction to treatment, so in prison or not. But if we have time, I want to add the angel and the devils are in lots of details. So this can be done really badly, or it can be done well. And—

QUINONES: Like everything. Like everything in this, you can do things. It’s all about—I’ve seen wonderful methadone clinics, and methadone clinics that act as hives of, you know. All of this, of course, is about how you do the details.

I did see one question that I wanted to get to, if I could. Tips for a student journalist at a college newspaper in a small town covering this issue. We know meth and homelessness are major issues in the town. I would say this, and this will, I think, lead you to more connection to places or are ideas that seem to be having some effect. And that is, it seems to me that the best sources are close—as close as you can get to the ground. For example, I do in jail and prison interviews all the time. Very, very important. For this story, I would say major sources of information are paramedics, ER docs and ER nurses, outreach workers who go into homeless encampments and whatnot, drug counselors, addicts themselves, obviously, recovering addicts, because frequently they have a clarity of mind and an ability to spend time and enunciate and articulate ideas that people who are strung out on the street don’t have.

I think once you get down into as close as you possibly can to the street—and that means also going to the jail and talking to people who are in the jail, or maybe talking to the—your drug court judge, or whatever you have in your town, these are all sources that are very—are not difficult to access. They are very, very important. And so if you’re struggling with ways of covering it in your town, I found too that when you talked with people on the ground, first of all, you’re up on the latest—they see things in real time. An ER doc, ER nurse, paramedic, they’re seeing it almost immediately as it hits your area. But also, it gives you an opportunity to see possibly what little things might be tried that might work.

So I would urge you, as a student journalist, to think about getting down as close as possible, and going to the jail, and asking for interviews there as well. It’s not hard to do. And it usually yields amazing results.

ROBBINS: Thanks. Is it Rachel—is it Mipro or Mipro—from the Kansas Reflector. Rachel, do you want to read your question quickly? And I think this’ll—

Q: Yeah, I would love to do it. It’s Mipro.

So this is going to be, like, a couple of questions wrapped into one. I mean, here in Kansas, our attorney general has tied this issue to illegal immigration. He’s saying, you know, we’ve got to crackdown on the southern border. And he’s also implemented, like, a law—a state law enforcement team to kind of try to crack down on this. So basically, my question is, is law enforcement seizure an effective way to prevent the spread? And then we’ve also heard a lot of China and Mexico role in this. And we’re hearing a lot of, usually Republican politicians, tie this sort of thing to illegal immigration rhetoric. Is there no in-house production of fentanyl? And how is this rhetoric part of the conversation? A lot of questions, sorry. (Laughs.)

ROBBINS: Vanda, this sounds like it’s one for you.

FELBAB-BROWN: Yeah, I just sat on my hearing yesterday that was all about this. So let me put some facts. And these are official U.S. government CBP facts. By the way, if you’re interested in this topic, I highly recommend watching the hearing. It was House Committee on Homeland Security and the hearing was very lengthy, a lot of details came out.

So more than 90 percent, or around 90 percent of all seizures occur in legal ports of entry. They are in—carried by predominantly U.S. citizens recruited by the Mexican cartels. And very frequently in U.S. license plates. The second large components still within that 90, it’s fentanyl being hidden in cargo. So in legal cargo, legal goods that are entering from Mexico. The number of migrants crossing the border, unauthorized migrants crossing the border between legal ports of entry carrying fentanyl, it’s a very, very small. It’s within the 10 percent category, but even that’s not a full number because some of the seizures are also occurring inland at points of entry, at vehicle checkpoints. So unauthorized migrants are not the primary or important carrier of fentanyl.

The second question was, do seizures matter? Seizures seek to do two things. They seek to limit the availability and they seek to boost prices. Seizures often do so very ineffectively. So, you know, in something like cocaine and heroin, the prices today are less than 20 percent of what they were in the 1980s, which will lead people in the drug policy community to say, see this isn’t effective. But this is only part of the answer. If you had no seizures, the price of both drugs would be far less than the 20 percent. So seizures and law enforcement make profits. This is what makes profits for criminal groups, but they still raise price. If you had no enforcement, then the price of a bag of cocaine would be exactly equivalent to the price of a bag of tea, and less for a bag of fentanyl.

So there is still—seizures and limiting supply is important. Directing it away from widely accessible places, like these pharmacies I was speaking about in Mexico or, for that matter, from us pharmacists and doctor over-prescribing the supply of legal opiates, this is still very important. It’s insufficient, but it’s very important.

What really needs to happen, and this is where there is this big hole in Mexico’s cooperation with the United States and in Mexico’s own law enforcement policy, is that in addition to seizures you want to be dismantling networks. You just don’t want to be shutting down a lab, because a lab is easy to recreate. But you want to be dismantling networks. And this is where Mexican action has essentially stopped after President López Obrador came to office.

QUINONES: Yeah, that’s right.

ROBBINS: So we—I’m going to put together all the same—we only have five more minutes—so I’m going to put together our remaining ones, which are all really good questions. Which is—well, Ryan Haas a question about the role of jails. You know, adopting this forced treatment approach. I want—Vanda wanted to comment about the—about the good and the bad of this. So I’m going to—Vanda, if you could quickly do that, then we’ll go back to Sam, and then we’ve got a few more questions. But you did want to comment about forced treatment, and both the good and the bad of it.

FELBAB-BROWN: So if prison simply to make people go cold turkey, is overwhelmingly ineffective. Even when people cannot source the drugs to which they are addicted in prisons, when they are released from prison, they will often end up very rapidly overdosing. And this is true not just from the United States. We see this from Saudi Arabia, Iran. We see this in China. We see this in Taiwan. If coerced treatment actually is meaningful treatment, then it can make a positive outcome.

So the greatest successes have come in projects like Project Hope, that would mandate that someone would be arrested or pulled over for driving under use, under influence, whether it be drugs or alcohol. And they would say, OK, you’re spending a night in prison. And next time we pull you over and you are still high, whether on drugs or on alcohol, you will spend five days—five nights or four nights in prison, escalating penalties. And people who were essentially controlled users, who had the ability to stop, we see dramatic decreases in their problematic behavior. And very strong success in alcohol and strong success even with other drugs.

Now you have a set of people who will simply be—have chronic deep disease. The coercive approach to them is far less—of limited success. And it might be that the coercive approach introduces them to some initial access to help, but a lot of other factors need to kick in for that help to be sustained. They will be chronically ill for most of their life.

ROBBINS: So, Sam, very quickly, Yomara Lopez, you want to ask your question, or shall I read it?

QUINONES: Can I say, I’ve read her question, and I don’t—I haven’t really investigated the Tenderloin sufficiently to know the answer to that. I’m sorry.

ROBBINS: OK. So Kate Walters, asks—I’ve got Siri talking back to me, it’s very confusing. Kate Walters asks: Can you expand a bit more on the role of harm reduction in addressing the current crisis? Other forms of harm reduction we should be thinking about? Sam, Vanda? And we only have two minutes, so quickly. (Laughter.) And if you don’t want to talk about that, you can talk about anything you want.

QUINONES: Let me talk about what Ryan was asking, because I think I want to make sure I get across that the reporting that I’ve done it has found in these—in these jails, first of all, that the pods that turn into—that transform into recovery pods are, you know, you opt in voluntarily. And then it’s all about recovery. So there’s no drugs in these recovery pods, even though there are drugs and the rest of the other parts of the jail. There are also social workers there who sign you up for Medicaid, so when you leave jail you are on Medicaid, which is very, very important.

Also, medically assisted treatment. It could be methadone. It could be Suboxone. It could be Vivitrol, whatever it happens to be. You also have in the jail I was writing about in my book, The Least of Us, in Kenton County, you have—extraordinarily important in all this is not just what goes on in jail but that there be a continuum of care that continues after release. Obviously, if it’s only in jail that you’re working, that when you leave it’s going to—you will very quickly return to using. And so to me this is an idea that I had not considered. I don’t think, as I’ve spoken about it around the country, I’m not seeing people actually ever having thought about it.

And it allows us to turn a negative, which is generally jail, although a lot of people, regardless of what’s available to them in jail use jail as a place to get clean. And I have talked to many people who have done that. It’s still not a place where we really can make the best of it. And you’re so you’re finding this rethinking of jail, all with the idea of what happens to this person when that person leaves the jail gates. And that is a radical idea too. It’s never really been part of what we—what we thought of as jail. And so my suggestion to folks is you might want to check in with some of the jails that are trying this.

Kenton County, Kentucky is one, and Covington, Kentucky. Columbus, Ohio has a new jail that’s just opening now. I think probably be fully—it'll be full by the time—by September. Remarkable, remarkable jail. Remarkable jail. That’s a state-of-the-art jail for the twenty-first century, with addiction being a major focus of what you’re seeing there. So I would say we don’t have a lot of time to talk about this. I would also just say that this is not the jail that you know, from the last fifty years. This is a very different way of thinking about jail, with different people working in jail. And to me, it seems appropriate—from my reporting—seems appropriate to the time we’re living in right now.

ROBBINS: I want to thank you both so much. We’re going to share both Sam and Vanda’s writing. Vanda has a fabulous piece in Foreign Affairs that talks about what we didn’t get to, which is the use of sanctions and other ways of pressuring governments, and working with Mexico and China potentially to perhaps get a better outcome here. Sam has an Atlantic piece. He’s written op-eds in the in the Washington Post. So we’re going to share some of their writing. We’ll also put in a link to the hearing, which I assume is online already from yesterday. And I’m going to turn it back to Irina. Thank you both so much. I learned an enormous amount. So thank you.

FASKIANOS: Yes, thank you all. And you can also follow Vanda on Twitter at @vfelbabbrown, and Sam at—on Twitter also—at @samquinones7. And as always, we encourage you to visit CFR.org, ForeignAffairs.com, and ThinkGlobalHealth.org for the latest developments and analysis on international trends and how they’re affecting the United States. And again, we encourage you to share your suggestions for future webinars. You can email us at [email protected]. So, again, thank you all for today’s really rich conversation. We appreciate it.

QUINONES: Thank you.

ROBBINS: Thanks, guys.

 

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