Written by Mitchell Gomez
MAPS Bulletin 2021, Volume 31, No. 3
Editor’s note: This article is slated for publication in the upcoming issue of the MAPS Bulletin. We have elected to publish it today, 12/22/21, given the news of a devastating increase in drug-related deaths, particularly for Native Americans.
In 1995, 48,371 Americans died from HIV, the highest year on record. This was just eight years after the first “AIDS quilt” and the massive public health response it evoked. Starting in 1996, these numbers began to fall, and thankfully have continued to decline virtually every year since (Ward, 1999).
Throughout the 1970’s and 80’s, motor vehicle deaths reached a point of up to 26 deaths per 100,000 people, with 50,000 or more deaths for 7 different years between 1970 and 1980 (Blincoe, 2010). Because of this public health crisis, there was a massive increase in motor vehicle safety programs, new laws passed against drunk driving, and the inclusion of an office for motor vehicle safety at the Centers for Disease Control and Prevention (CDC).
In 2020, 93,331 Americans died from drug-related incidents in the United States (U.S.), an increase of nearly 30% from 2019 . This number, more than twice the highest year of HIV deaths, and nearly twice the highest year of vehicle deaths, represents the leading causes of death for people under the age of 44, even during a global pandemic which has killed nearly 700,000 Americans. Despite this, the public health response to drug related deaths has been lackluster at best, with many in the government and media continuing to misleadingly call these deaths “overdoses.” Although this is medically accurate terminology (where “overdose” is generally used to denote “a pathological level of drug toxicity”), the public perception of an overdose is when a person consumes too much of the substance they were intending to consume.
But that is not what is happening in the U.S. today.
What we are experiencing in the U.S. today is not an “overdose crisis” in any but the most technical sense. What we are experiencing is a massive and accelerating drug misrepresentation crisis, where people are being killed by dangerous adulterants and dishonest substitutions, not by consuming “too much” of the substance they intended to consume.
All unregulated markets suffer from the problem of misrepresentation. From counterfeit medications in Africa and Asia, to the thousands of Americans who died from poisoned methanol under alcohol prohibition, this problem is endemic to any system of prohibition. The dynamics of prohibition leading to more potent analogues is so well understood it has been named the “iron law of prohibition” by Richard Cowan in 1986, and posits that as law enforcement becomes more intense, the potency of these prohibited substances increases. Cowan paraphrased this law as: “the harder the enforcement, the harder the drugs.”
In MDMA markets, misrepresentation is widespread, with an entire galaxy of substituted cathinones and related substances (which the media insists on calling “bath salts”), many of which have a much higher risk profile than MDMA, being sold throughout the country. For many years, 25I-NBOMe was commonly being sold as “acid,” resulting in dozens (or perhaps hundreds) of deaths of people who were trying to consume LSD, a drug with no known fatal dose. The ketamine markets have been flooded with a whole family of dissociative analogues, many structurally related to PCP, some of which have longer time arcs, or higher risk of physiological problems. Counterfeit “Xanax” pills are also common, often made with other benzodiazepine or benzodiazepine analogues such as bromazolam and etizolam, as are counterfeit “Adderall” pills made with other stimulants, including methamphetamine and even phentermine (one half of the old diet drug fen-phen).
Occasionally there are incredibly strange misrepresentations, like a case of AB-FUBINACA, potent agonist for the cannabinoid receptors, being sold as “MDMA.” Because AB-FUBINACA is more expensive per gram than MDMA, and is almost exclusively sprayed on inert matter to be smoked as “synthetic marijuana,” this misrepresentation makes no rational sense from either a financial or experiential understanding of drugs. There have also been cases of potent and expensive opiates that were shipped from the dark web as “DMT.” The only explanation I can think of for misrepresentations of that type are mixed up baggies somewhere up the distribution chain. No matter what the specific misrepresentation, the underlying cause remains. Any unregulated market will always be subject to these issues.
In opiate markets, rampant misrepresentation really began to accelerate in 2010 as the Drug Enforcement Administration (DEA) and state authorities cracked down on so-called “pill mills,” especially in Florida. As a direct result of the closure of many doctors’ offices willing to prescribe prescription opiates, the U.S. saw a massive increase in heroin consumption as individual consumers were cut off from their supply of prescribed opiates. As the increased demand for heroin overwhelmed production and distribution capabilities, and as border patrol was ramped up under the Trump administration, drug sellers continued to switch to ever more potent analogues in place of heroin.
Misrepresentation is nowhere more common, or deadly, then when it comes to the current fentanyl wave. In many cities, drug distributors no longer even have the pretext that they are selling heroin, and instead just call any powdered or “black tar” looking opioid drug they are selling “down.” Fake opioid pills are now also widespread, and in many places ANY opiate pill not received at a pharmacy is exceedingly likely to just be pressed fentanyl and binder.
Although fentanyl has been used medically since it’s invention and patenting in the 1960’s, and is still today the most common surgical and cancer treatment pain management tool, it was widely confined to medical use for decades. Although the first “unregulated use” deaths from fentanyl date to the early 1970’s, these were a rarity until the dynamics explained above caused sellers to switch to fentanyl en masse.
Although the fentanyl crisis began in opioid markets, it has now spread far beyond unregulated market heroin. Deaths from “fentanyl-adulterated cocaine” are now so common and widespread that they no longer even make the news, unless the victim happens to be famous. Despite the fact that cocaine and fentanyl are entirely unrelated drugs, they are still called “fentanyl overdoses” by the media and government. There have also been confirmed samples that were sold as MDMA, ketamine, and even N,N-DMT containing fentanyl.
I get asked all the time why fentanyl is ending up in so many non-opioid substances. This question often comes from grieving families and friends who are looking for answers, but is also sometimes asked to me by the very experts our society should be able to turn to in times like these such as doctors and epidemiologists. The most common explanation given by law enforcement, that fentanyl is added to non-opioid drugs to “make them more addictive” is frankly nonsense. A person who sells fentanyl to someone seeking a non-opioid drug isn’t going to get a new customer, they’re going to get a very angry one (or a dead one?). The theories I have heard are both varied and, to be frank, wild and range from accidental cross-contamination, to non-state actor terrorism, to philosophical prohibitionists poisoning the drug supply to discourage use. As a society, we cannot fix a problem until we understand the causes of that problem, and calling these “overdoses” seeks to obfuscate what they really are. No matter what the reason, or combinations of reasons that this is happening, there is one underlying cause for it all.
Fentanyl ends up in other drugs because those drugs are illegal, and not being distributed through a regulated supply.
On June 18, 1971, President Richard Nixon gave a speech during which he declared drug abuse “public enemy number one”, launching the modern war on drugs. That year, 6,771 Americans died from what the CDC at the time called “drug poisonings.” Since that time, the United States has spent over a trillion dollars on fighting the war on (some people who use some) drugs. We have locked up a larger prison population (both per capita and in absolute numbers) than any other civilization in the history of the world.14 We have eroded the 1st and 4th Amendment to the point that they are hardly recognizable, and we have created a massive, unchecked bureaucracy in the DEA with the power to write the laws they are charged with enforcing. On top of all of this, over a million Americans have died from drug incidents since that dark day.
What has this bought us? What have we gained?
There are, of course, many mitigations that we can deploy to reduce the rate of fentanyl deaths. The distribution of narcan, to both drug users and non-drug users alike, is extremely helpful. Educating everyone about fentanyl adulteration, starting in middle schools, and how to test using fentanyl test strips can also reduce these incidents. But all of the mitigation techniques in the world can’t fix a problem that is intrinsic to prohibition, and only ending prohibition can truly end this problem.
What the United States (and the world) needs is clear. The only way to end these deaths is with the legalization of not just drug possession, but of drug supply.
Only with full legalization will we be able to regulate drug markets, educate all people about how to mitigate the risks of use, and bring an end to the largest public health crisis in U.S. history.
Mitchell Gomez is a graduate of New College of Florida (whose Alumni include the founders of Erowid, MAPS, and the Zendo Project), and has his Master’s degree from CU Denver. Mitchell has been a part of the electronic music community since the late 90’s, when he first started attending underground shows while still in high-school. He has worked in event production, festival entertainment, and promotion. Mitchell joined DanceSafe as their National Outreach Director in 2014 and was responsible for all volunteer coordination, including the development, implementation, and evaluation of new training curriculum and all outreach initiatives. He has volunteered with the Burning Man organization, Students for Sensible Drug Policy (SSDP), and other small harm reduction projects for many years, and is a passionate advocate for reality-based drug policy and harm reduction. In March of 2017 he was promoted to Executive Director of DanceSafe (dancesafe.org), continues to remain active in outreach activities, and is one of the leading anti-prohibitionist voices today.
Ward, D. E. (1999). The AmFAR AIDS Handbook. W. W. Norton & Company.
Blincoe, L.J.; Miller, T.R.; Zaloshnja, E. and Lawrence, B.A. 2015. The economic and societal impact of motor vehicle crashes, 2010 (revised). Report no. DOT HS-812-013. Washington, DC: National Highway Traffic Safety Administration.
Cowan, Richard (December 5, 1986). “How the Narcs Created Crack: A War Against Ourselves”. National Review. 38 (23): 26–34