>> Researchers have pondered what could have caused this sudden turnaround, pointing to the end of the covid-19 pandemic or a rise in drug treatment. A new article, published in Science on January 8th, suggests, instead, that a supply shock drove the decrease.
The supply shock sounds right.
I was volunteering at a state run institution, who had an addiction data science team, at the peak of the opioid crisis. I was developing ml models to predict patient dropout early in a 32 week program. The data and funding for such research was very scarce and it didn't go anywhere.
Treatment for opioid use disorder with medication is highly effective for 50% - 90% who respond well to treatment. The problem with the bottom 50% was early dropout, due to the lack of dissemination of proper treatment protocols and stigma attached to medication for treatment (methadone). I stopped following the work, I became too sensitive, it was pretty depressing.
The pandemic coupled with the increase in illicit fentanyl was just tragic in what it did to people. I remember reading the DEA research, where the precursor for fentanyl came from china and was manufactured and distributed from mexico. Mexico was also manufacturing high quality meth and displaced most of the meth labs in america, coming with increases in meth overdose during the same period. The fentanyl was so cheap compared to traditional heroin manufacturing.
I'm glad the supply seems to have dried up. It was nuts, what was going on a few years ago.
You can live with a sustained opioid addiction permanently without major issues. That’s the entire basis of methadone clinics - controlled dispersement of opioids at a level that solves cravings and allows the addict to be functional. It is very sad we don’t allow pharmaceutical grade opioids to be given to addicts in a controlled way, it would eliminate the purity variance that causes overdoses, and prevent the poison mixed in to increase street profits from destroying bodies (tranq, etc)
Even still today there is no reliable place to source black tar or China White or any of the traditional opium derivatives without having a fentanyl cut.
Isn't this more because the supply of poppy was cut off when the US pulled out of Afghanistan? Users want the good stuff, dealers buy the cheap and available stuff and pretend it's real.
I think that many methadone clinics are operating very unethically, to the point I would call it fraudulent. Certainly it's cruel to the patients. They essentially set up the patient to be a lifetime methadone addict. This may be an improvement over getting your fix on the street but it's still addiction dependence and it's expensive (profitable!). I'm unsure if it's just a few or a large fraction of them that operate this way. Maybe my data point is a unique outlier but here's what I saw:
I had a friend who was going through the program in Springfield Missouri, approximately 10 years ago, and the clinic literally increased his dose every week or two. They also had strict controls to make sure the patients actually take the full dose (because otherwise they might sell some of it on the street). So they were left with just 2 options, either drop out of the program and find their fix elsewhere, or accept a gradually increasing dose of methadone, forever. It's a sick program that is set up to make sure patients gradually descend deeper into addiction while they rake in huge profits. It's not really any different from what the drug dealers on the street are doing except that it's even more exploitative and dishonest. The doctors had zero plan for weaning people off of the methadone and some people had been on the program for years, with correspondingly huge doses doled out to them every time they came in. This was 10 years ago, at the time it cost something like $50 per visit, paid by the patient or possibly medicaid.
Well, addiction or not, the main question is what medics call "quality of life" -- whether a patient can life their life to the full potential.
There are millions of people addicted to caffeine, the most popular psychoactive substance in the world, but as it usually doesn't prevent them to live their life and "be a productive member of society", no one cares of treating caffeine addiction, save for religious societies.
My point is -- is methadone addiction "better" than fentanyl in that regard? If yes, than that's ok.
My complaint was about the forced increasing of dosage. They literally would not allow the patient to wean off of it. So yes, it might be an improvement over the shit on the street but it's diabolical that they force patients to continually increase their dose rather than gradually decreasing it.
I have no idea if this is common or just this one shady clinic but my data point of 1 still stands. If there is one, then given that this would be very profitable, it's highly likely that there are other clinics with similarly unethical policies.
To answer my own question: what you described sounds like part of the standard recommended protocol, and it seems likely your friend misunderstood or misrepresented that.
I'll explain with liberal quotes from the document linked below. Dosages start out low to avoid risk to the patient, because "the most common reason for death or non-fatal overdose from methadone treatment is overly aggressive prescribing/dose-titration during the first two weeks of treatment."
Because of this, "methadone induction and titration MUST be approached slowly and cautiously. It may take several weeks to address opioid withdrawal
effectively. It is important to be upfront with patients about this requirement and to discuss ways to cope with ongoing withdrawal and cravings, to maintain engagement in treatment."
The dose increase is described in the following paragraph:
"...methadone can be initiated without the prerequisite presence of opioid withdrawal. This may be preferential for some patients. The patient’s dose should be titrated with a “start low and go slow” approach, based on regular clinical assessment, until initial dose stability is reached – see specific recommendations below. A stable dose is achieved when opioid withdrawal is eliminated or adequately suppressed for 24 hours to allow patients to further engage in ongoing medical and psychosocial treatment. The ultimate goal is to work toward clinical stability."
In other words, for patients who are continuing to take other opioids, the methadone dose is increased over time to make it easier for the patient to reduce that other intake. Dosage is based on interviews with the patient.
Addicts are very good at subconsciously coming up with rationales for remaining addicted. It's much more likely that your friend found himself in that trap, than that he was going to an unethical clinic trying to keep him addicted "forever". That would be a major violation of the law and breach of medical ethics, and would be likely to come to the attention of regulators if it was a recurring pattern.
It's possible my friend wasn't telling me the whole story or just misunderstood the program. I don't think he was actually trying to stay addicted though because after a few weeks on methadone (with increasing doses and doctors telling him that he would always be an addict for life) he decided to take the more extreme route of getting clean by quitting cold turkey. He moved to a different state and cut ties with every possible source he had to acquire the drugs.
And yet, you're comfortable accusing the people trying to cure addicts of some diabolical plot to ensnare them into permeant addiction in order to make money off them forever. Maybe next time you'll think before you propagate nonsense.
This is certainly possible, but it sounds more like what AA tells its clients. Doctors are less likely to say things like this, because it can have consequences for them.
Going cold turkey like you're saying he did is fine if (1) it doesn't kill you and (2) you're able to do it. For many people, it's just not very practical.
I don't think it's a good idea to demonize medical professionals for doing their jobs to the best of their abilities in the face of enormous challenges. That's the kind of thing that the conspiracy theorist and anti-science Robert F. Kennedy Jr. does, and it's not helping the US in any way at all.
Not that I'm aware of, it seemed rather arbitrary. The people who had been going to that clinic for a while all had massive doses, almost to a ridiculous degree. My perception was that it was to keep them hopelessly addicted. I was only peripherally involved as it was my friend who was the patient. He was very fortunate to have family with influence in the Mormon church - his family had the church send some local missionaries to help him - and they genuinely did help him escape that terrible situation.
Methadone is effective because it comes with lower respiratory fatigue.
If you have a nasty addiction, methadone is the gold standard for treatment. It's really all that's available to ween people down.
There are other medications for maintenance like buprenorphine and naltrexone. But you can't take those if you're in the throws of heavy addiction, you can die.
The claim that fentanyl death rates are decreasing because fentanyl products are less pure does not make much sense. Even on their provided charts, deaths dropped months before purity did.
The article points to a 50% decrease in purity, which a habitual user would compensate for by taking twice as much. Lower average purity also increases the risk of inconsistent purity, where rare batches are unexpectedly strong and carry high accidental overdose risk. Less pure fentanyl floating around might mean lower chances of unsuspecting non-fentanyl drug users being poisoned with it, but it's hard to see how this could cut into overall overdose cases.
> article points to a 50% decrease in purity, which a habitual user would compensate for by taking twice as much
I’ll be first to admit I’m generally pretty ignorant on this topic but I’ve heard a plausible explanation for how Fentanyl is actually used.
A medical professional shared with me that Fentanyl is too potent to be consumed as is. So generally, dealers use it as an additive. They lace other drugs with trace amounts of to make them more addictive. It’s the MSG of drugs.
So while ODing on say, drug A is possibly with 5 uses at once. When laced with Fentanyl, a person might OD in just 3 uses (because Fentanyl is much more potent than the actual drug the user bought).
To be blunt it was total bullshit. Pharmaceuticals have an extremely wide range of dosages. Fentanyl is on the extreme low end, benadryl an adult might take 25 mg or 50 mg, tylenol an adult might take 500 mg, and something like amoxicillin an adult might take as much as 3000 mg for a severe infection. There are standard, extremely reliable ways to prepare pills that contain the correct dosage regardless of the potency of the pure chemical.
Obviously fentanyl (or its precursor) is imported (ie smuggled) in highly pure form in order to minimize the size of the shipment. Obviously it can't be consumed in that form.
The combination of being potent and cheap to smuggle lends itself nicely to cutting other (more expensive) products with it. That's false advertising but it won't typically kill you in and of itself.
When laymen who don't know what they're doing, don't have access to proper facilities, and certainly can't set up proper quality controls process something that potent it's no wonder that things go wrong and people die. If (for example) the same victims had purchased fentanyl from a pharmacy (as opposed to whatever it was they thought they were consuming) they almost certainly would not have had any issues. Almost no one ODs intentionally.
The point is that it's not "fentanyl is toxic so you OD" it's "the person compounding the pill messed up the dosage, you took more than you thought, so you OD". This could happen just as easily with any other drug. The danger here is due to pills not containing the dosage that the consumer believes them to.
Other drugs aren't dosed in micrograms. It's pretty believable that street labs don't having the precision to get reliable dosing in such small quantities. 50/100mcg is the typical ambulance dosing of fentanyl (where it's often used as the primary painkiller) - so at 500 times smaller than that of benadryl, it would take a reasonably high-end lab (at least by mid-level drug dealer standards) to not wildly mess up the dosing all the time - even if you mixed at larger scales, that still doesn't easily guarantee a uniform blend.
It couldn't happen "just as easily" with any other drug.
Fentanyl isn't too potent to be consumed as-is, but the dosage is very very small. The amount of fentanyl that will kill you is literally invisible. The LD50 appears to be well under 0.01mg/kg (that is, a milligram will kill a 220lb person).
British Columbia declared the toxic drug crisis an epidemic in 2016, with the amount of deaths amounting to 6-7 a day through this period until now.
The article's theory is compelling but given the incredible amount of deaths, thousands upon thousands of deaths in BC alone, I wonder if the rate of death is declining simply because we're running out of people to kill with our indifference.
Killing addicts more quickly than creating new ones would indeed eventually lead to a decrease in drug related deaths. I would really believe this because I know of multiple people that died from ODs in a fairly short window 4-5 years and that spans a range of about 12 years of people. As in to say everyone I know age 24-36 about half of those people that were opiate users died from about 2019-2023 due to fent. All of them that I know the details of were from fake pills too, so very much related to fentanyl.
Long term you couldn't kill more than existed, asymptotically the maximum number of ODs per unit time would be exactly equal to the number created, impossible to be more.
> running out of people to kill with our indifference.
I wouldn't call it indifference. It's the drug policies that we've very intentionally adopted in the west that result in people purchasing from the black market. It's about as indifferent as the deaths due to denatured alcohol poisoning during prohibition when the additive was silently switched.
What happened to the theory that the deaths were decreasing because we burned through our buffer of people susceptible to deaths of despair? That always seemed reasonable to me.
So, statistics clearly show that limiting drugs supply actually works, unlike what the hard left has been saying to us (backed by social “sciences”) since the 2000s?
If we just listened to common sense instead of these people, society would be saved from a lot of pain.
The reporter rightly queried other researchers about this article, and all of them were skeptical that a "supply shock" could be the cause, or even the main cause. My own skepticism is because the death rate went down many months before any sign of shortage appeared.
I haven't read the paywalled Science paper, but The Economist extracted a graph which shows that the purity of Fentanyl pills was stable till the first months of 2024, then dropped sharply. The purity of the powder peaked in 2023, then went down in 2024, back to its older levels. They suppose that it proves the supply was short, but another researcher even states that the supply of Fentanyl precursors didn't change until the end of 2024.
What is your supposition here? That addicts are keeping narcan around just in case? That good friends of addicts are standing by with the spray in case it is needed? That your local opium den had staff with it on hand?
Narcan should be available, but short of a few users that know they need to keep it around, I don’t buy that making it available has meant a significant change in total outcomes because of timely deployment.
Yes to all of the above. I knew of addicts who managed to get their hands on it many years ago when it required a prescription. Most weren't that resourceful though.
You might have got some at a rehab centre, or someone might live with a non-addict friend or partner. Community outreach workers (in cities that have embraced this stuff) might carry some around to administer.
I would be surprised if widespread availability to Narcan didn't decrease ODs.
Changes in purity, especially when unknown to users, is going to affect hospitalizations and such no doubt, but the people using it also adapt to the purity of a drug over a longer timespan.
Even if people wanted to its not like they can all just bring a sample of their old heroin and a sample of their stronger high fentanyl laced heroin and test their purity and calculate dosages. Which is part of the problem of the war on drugs, many methods of harm mitigation and recovery are barred from users and 90% of their drug information is based on hearsay or personal experience.
> part of the problem of the war on drugs, many methods of harm mitigation and recovery are barred from users
That is a problem for the US, sure. Australia, where I live, has supervised shooting galleries and more of an addiction as health issue approach.
That said, if you had a chance to look at the US graphs linked above - there was a plateau period of high deaths in the US of some three and half years showing no much evidence of users learning to "safely handle and dose fentanyl" followed by a sharp decrease in deaths that corresponds more with a change in policy than an increase in user knowledge.
I would suggest this may be a somewhat more complex and multivariate issue than your initial upthread postulate acknowledges.
I thought this was already well-established public information? That fentanyl came mostly from China was never in doubt, what people were arguing about was whether this was happening with the tacit approval of the Chinese government. Then in 2023 China cracked down on it, and supplies dried up. Whether that was because it was a big enough issue to get their attention, or it was on purpose and they decided it was no longer serving their interests I suspect we'll never know, but I definitely read multiple articles in 2023 about the fentanyl crackdown in China.
Biden era cooperation with China on the issue was at the heart of this.
It wasn't about the direct supply of Fentanyl, or even (by that stage) the direct supply of Fentanyl precursor drugs .. (that gangs used to industrial shed chem lab into Fentanyl) ... this was cutting back and limiting bulk supply of the precursor precursors to shady onselling networks to starve the labs.
Was going well (as per the paper) until US / China relations went in the toilet.
Mexico also began enacting extremely heavy handed tariffs against China and other Asian exporters like South Korea, India, and Vietnam in 2023 onwards [0][1][2][3] in order to protect their domestic manufacturing capacity against an export-driven supply shock, which hit Mexico really badly in the 2000s [4].
> Was going well (as per the paper) until US / China relations went in the toilet
Yep, but as long as Mexico continues to enact trade barriers to protect against an Asian export shock, the APIs needed for synthesis will remain difficult for organized crime to acquire.
Already, cartels have begun tariff arbitraging by targeting the CEE and the Balkans as a new base for synthetic opioid operations [5][6][7], especially because Romanian [8] and other CEE gangs had been collaborating with Mexican organized crime on financial and human trafficking crimes in Mexico for over a decade now.
The biggest takeaway that deserves stressing over and over again is that Things Take Time .. it generally takes 18 months and longer to substantially impact global flows.
The work has to be put in early, kept up in practice, and results are often credited to political actors down the road of time.
People are always talking about this precusor from China, but I have no idea what this precursor is. Are they chemicals that are useful for lots of things or is it only useful for this? Because if it is the former, then China is just selling regular ass legal chemicals because they are the worlds number 1 supplier of manufactured goods.
Fun fact: The "traditional" way of making it was extracting piperine from black pepper and reacting that with nitric acid. Nowadays it's made in other more industrial scalable ways.
But yes, the same base precursors (and their siblings) are used to manufacture ADHD meds (ritalin/concerta), antidepressants (paxil), insect repellents (picaridin/bayrepel), hair loss medications (rogaine), allergy meds (claritin), anti-psychotics (haldol), anti-diarrhea meds (imodium), and many others. And also PCP.
So it's non-trivial to prevent. The core of the issue is that the one pot Gupta method came about in the 2000s and it made it extremely easy to manufacture fentanyl using these basic building blocks for so much of the pharma industry. Not only just making it easier to source ingredients but it took out all the steps and made the process easy as hell as well.
The challenge in international drug operations was not to get China to stop selling bricks to house builders to but get China to cooperate in stopping the sale of bricks to groups that only use bricks to throw through windows and at heads.
Fentanyl is so potent that just one lab can easily satisfy all the US demand with it, around 10kg a day. That's also why it's ridiculously hard to fight, one smuggled barrel of pure product can supply the entire US for months.
So no, there is no "supply shock". There's just more free Narcan (naloxone).
Cocaine death decreases is the hard thing to explain with either theory, supply or naloxone. Fentanyl supply doesn't affect cocaine in any way and naloxone doesn't work on a cocaine OD.
Maybe some percentage of cocaine deaths are misattributed fentanyl deaths?
I also wonder if there's any link to the Oxycontin reforms. Perhaps now that prescription is reigned in, we are seeing a lot fewer oxy->fent cases which has cut back on the deaths.
Or maybe it's actually that the drug dealers have gotten more careful. Drug dealers don't want to kill their clients, so maybe they've been purposefully diluting to make sure they get repeat customers.
> Perhaps now that prescription is reigned in, we are seeing a lot fewer oxy->fent cases which has cut back on the deaths.
This is definitely part of the story. When your primary source of new addicts is prescription opioids and you cut down on the prescriptions then over time, as people die off from OD, then the OD rate is bound to drop.
The most tragic part of it, to me, is that it's usually the people who got clean who eventually OD. Once they've been clean for a short time then their tolerance for the drug drops drastically, then if they break down and do "just one dose" they make the fatal mistake of thinking they can still handle the same amount they were used to doing before. This exact scenario happened to multiple more or less close acquaintances of mine, even people who were aware of tolerance and should have known better. I'm fairly sure that it's extremely common.
"Drug overdose deaths may involve multiple drugs; therefore, a single death might be included in more than one category when describing the number of drug overdose deaths involving specific drugs."
https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
Someone who overdosed after taking cocaine contaminated with fentanyl would be counted as a cocaine ODD.
The Oxycontin "reforms" caused the fentanyl crisis to begin with. People often moved onto heroin and fentanyl because pharmaceuticals were no longer accessible. The massive spike in overdose deaths begun after the decline in opioid prescriptions. See the Opioid Prescriptions & Opioid Overdose Deaths graph here https://drugabusestatistics.org/opioid-epidemic/
Pure cocaine overdose deaths are relatively rare. Only around 5% of cocaine deaths involved pure cocaine, it's almost always mixed with something else.
> I also wonder if there's any link to the Oxycontin reforms. Perhaps now that prescription is reigned in, we are seeing a lot fewer oxy->fent cases which has cut back on the deaths.
Prescription pills have been a non-issue for a decade by now.
> Or maybe it's actually that the drug dealers have gotten more careful. Drug dealers don't want to kill their clients, so maybe they've been purposefully diluting to make sure they get repeat customers.
Yup. I think that's exactly it.
The major reason for fentanyl deaths was not unintentional overdose because of poor pill quality. It was way too easy to end up with 1mg instead of 500mcg during pill mixture preparation. So _reducing_ the amount of fentanyl per pill results in a better safety margin. And users can just smoke another pill if one pill was not enough to get high, after all.
And yeah, it's just possible that the more reckless drug users are just dead by now. But to be clear, it's still absolutely horrible. We're still above the 2021 level.
"Supply shock" might not be the only, or even primary cause. As far as I know fentanyl is still widely available and inexpensive.
My guess is only a subset of the population is willing to both A) Use a substance like street fentanyl with known lethality. and B) Do so in a risky and unsafe manner (alone, no narcan, shooting instead of smoking, etc. etc.).
That subset of the population has already been decimated to the point we are seeing a decrease, and survivors have become more educated on how to use without dying.
My dad was a heroin addict, and while he eventually got (mostly) clean, he wryly joked to me once "you know there aren't a ton of old heroin users for a reason"
Using street drugs kills - we can put people on opiates if done in a controlled way, for the rest of their lives, we instead have gone down the road of prohibition, closing off pathways for people to get maintenance dosing of opiates.
> fentanyl powder and pills were losing potency just as overdose deaths were falling
Combined with the already dead, does this not explain things?
Illegal drug suppliers don't make money by killing their customers. Consequently, they finally got control over the potency throughout their supply chain.
Although, I'm more interested in the standard deviation of the potency than the absolute value of the potency. I suspect that is much more correlated with OD deaths.
Just a different form of supply shock - to the supply of users.
Living in downtown SF for the last two years has made it painfully obvious those using fent on the streets are not long for this world. It'd an inherently self-solving problem, grim but true.
Not all (probably not even most) destitute people become opiate addicts. People become destitute because they are opiate addicts, it's not the other way around.
The article says something along these lines. Every pandemic has a peak point when people become alarmed, and there is a clear way to avoid contamination.
It happened with AIDS when people began stopping having risky relations. It is only natural that it would also happen in drug addiction when everyone sees its devastating effects.
The same thing might be happening to tobacco and alcohol consumption.
Deaths for lack of vaccines (e.g. measles) will also behave the same way. When people see very explicitly that risky behaviour has consequences, they think twice before doing it.
> When people see very explicitly that risky behaviour has consequences
With much emphasis on the "very explicitly" part.
It seems to only work that way when it is very explicit and rapid consequences. Abstract consequences far in the future are not very effective at deterring [ entertaining | desirable | fashionable | profitable ] behavior.
"The same thing might be happening to tobacco and alcohol consumption."
I believe the data on smoking was the opposite. Showing people the terrible consequences of smoking (including very graphic images) turns out to have minimal or no effect. There was a large randomized trial in the pacific northwest some decades ago. A lot of people now point to taxes as the main driver in the decrease.
archive: https://archive.is/C0Y0G#selection-1303.143-1303.175
this is my best guess for the research cited (paywalled): https://www.science.org/doi/10.1126/science.aea6130
If true, the next question is what caused the supply shock?
>> Researchers have pondered what could have caused this sudden turnaround, pointing to the end of the covid-19 pandemic or a rise in drug treatment. A new article, published in Science on January 8th, suggests, instead, that a supply shock drove the decrease.
The supply shock sounds right.
I was volunteering at a state run institution, who had an addiction data science team, at the peak of the opioid crisis. I was developing ml models to predict patient dropout early in a 32 week program. The data and funding for such research was very scarce and it didn't go anywhere.
Treatment for opioid use disorder with medication is highly effective for 50% - 90% who respond well to treatment. The problem with the bottom 50% was early dropout, due to the lack of dissemination of proper treatment protocols and stigma attached to medication for treatment (methadone). I stopped following the work, I became too sensitive, it was pretty depressing.
The pandemic coupled with the increase in illicit fentanyl was just tragic in what it did to people. I remember reading the DEA research, where the precursor for fentanyl came from china and was manufactured and distributed from mexico. Mexico was also manufacturing high quality meth and displaced most of the meth labs in america, coming with increases in meth overdose during the same period. The fentanyl was so cheap compared to traditional heroin manufacturing.
I'm glad the supply seems to have dried up. It was nuts, what was going on a few years ago.
The initial spike in overdose deaths were largely caused by government crackdowns on pharma drugs.
You can live with a sustained opioid addiction permanently without major issues. That’s the entire basis of methadone clinics - controlled dispersement of opioids at a level that solves cravings and allows the addict to be functional. It is very sad we don’t allow pharmaceutical grade opioids to be given to addicts in a controlled way, it would eliminate the purity variance that causes overdoses, and prevent the poison mixed in to increase street profits from destroying bodies (tranq, etc)
Methadone is available in the UK, on the NHS. I know at least one person who has been on it for decades.
https://www.nhs.uk/medicines/methadone/
Even still today there is no reliable place to source black tar or China White or any of the traditional opium derivatives without having a fentanyl cut.
Isn't this more because the supply of poppy was cut off when the US pulled out of Afghanistan? Users want the good stuff, dealers buy the cheap and available stuff and pretend it's real.
I think that many methadone clinics are operating very unethically, to the point I would call it fraudulent. Certainly it's cruel to the patients. They essentially set up the patient to be a lifetime methadone addict. This may be an improvement over getting your fix on the street but it's still addiction dependence and it's expensive (profitable!). I'm unsure if it's just a few or a large fraction of them that operate this way. Maybe my data point is a unique outlier but here's what I saw:
I had a friend who was going through the program in Springfield Missouri, approximately 10 years ago, and the clinic literally increased his dose every week or two. They also had strict controls to make sure the patients actually take the full dose (because otherwise they might sell some of it on the street). So they were left with just 2 options, either drop out of the program and find their fix elsewhere, or accept a gradually increasing dose of methadone, forever. It's a sick program that is set up to make sure patients gradually descend deeper into addiction while they rake in huge profits. It's not really any different from what the drug dealers on the street are doing except that it's even more exploitative and dishonest. The doctors had zero plan for weaning people off of the methadone and some people had been on the program for years, with correspondingly huge doses doled out to them every time they came in. This was 10 years ago, at the time it cost something like $50 per visit, paid by the patient or possibly medicaid.
Edited slightly for clarity.
Well, addiction or not, the main question is what medics call "quality of life" -- whether a patient can life their life to the full potential.
There are millions of people addicted to caffeine, the most popular psychoactive substance in the world, but as it usually doesn't prevent them to live their life and "be a productive member of society", no one cares of treating caffeine addiction, save for religious societies.
My point is -- is methadone addiction "better" than fentanyl in that regard? If yes, than that's ok.
My complaint was about the forced increasing of dosage. They literally would not allow the patient to wean off of it. So yes, it might be an improvement over the shit on the street but it's diabolical that they force patients to continually increase their dose rather than gradually decreasing it.
I have no idea if this is common or just this one shady clinic but my data point of 1 still stands. If there is one, then given that this would be very profitable, it's highly likely that there are other clinics with similarly unethical policies.
To answer my own question: what you described sounds like part of the standard recommended protocol, and it seems likely your friend misunderstood or misrepresented that.
I'll explain with liberal quotes from the document linked below. Dosages start out low to avoid risk to the patient, because "the most common reason for death or non-fatal overdose from methadone treatment is overly aggressive prescribing/dose-titration during the first two weeks of treatment."
Because of this, "methadone induction and titration MUST be approached slowly and cautiously. It may take several weeks to address opioid withdrawal effectively. It is important to be upfront with patients about this requirement and to discuss ways to cope with ongoing withdrawal and cravings, to maintain engagement in treatment."
The dose increase is described in the following paragraph:
"...methadone can be initiated without the prerequisite presence of opioid withdrawal. This may be preferential for some patients. The patient’s dose should be titrated with a “start low and go slow” approach, based on regular clinical assessment, until initial dose stability is reached – see specific recommendations below. A stable dose is achieved when opioid withdrawal is eliminated or adequately suppressed for 24 hours to allow patients to further engage in ongoing medical and psychosocial treatment. The ultimate goal is to work toward clinical stability."
In other words, for patients who are continuing to take other opioids, the methadone dose is increased over time to make it easier for the patient to reduce that other intake. Dosage is based on interviews with the patient.
Addicts are very good at subconsciously coming up with rationales for remaining addicted. It's much more likely that your friend found himself in that trap, than that he was going to an unethical clinic trying to keep him addicted "forever". That would be a major violation of the law and breach of medical ethics, and would be likely to come to the attention of regulators if it was a recurring pattern.
https://cpsm.mb.ca/assets/PrescribingPracticesProgram/Recomm...
Was there some stated rationale for the dose increase?
It's possible my friend wasn't telling me the whole story or just misunderstood the program. I don't think he was actually trying to stay addicted though because after a few weeks on methadone (with increasing doses and doctors telling him that he would always be an addict for life) he decided to take the more extreme route of getting clean by quitting cold turkey. He moved to a different state and cut ties with every possible source he had to acquire the drugs.
And yet, you're comfortable accusing the people trying to cure addicts of some diabolical plot to ensnare them into permeant addiction in order to make money off them forever. Maybe next time you'll think before you propagate nonsense.
Did it work? Is he clean?
Yes it worked.
This is certainly possible, but it sounds more like what AA tells its clients. Doctors are less likely to say things like this, because it can have consequences for them.
Going cold turkey like you're saying he did is fine if (1) it doesn't kill you and (2) you're able to do it. For many people, it's just not very practical.
I don't think it's a good idea to demonize medical professionals for doing their jobs to the best of their abilities in the face of enormous challenges. That's the kind of thing that the conspiracy theorist and anti-science Robert F. Kennedy Jr. does, and it's not helping the US in any way at all.
Not that I'm aware of, it seemed rather arbitrary. The people who had been going to that clinic for a while all had massive doses, almost to a ridiculous degree. My perception was that it was to keep them hopelessly addicted. I was only peripherally involved as it was my friend who was the patient. He was very fortunate to have family with influence in the Mormon church - his family had the church send some local missionaries to help him - and they genuinely did help him escape that terrible situation.
Agreed.
Methadone is effective because it comes with lower respiratory fatigue.
If you have a nasty addiction, methadone is the gold standard for treatment. It's really all that's available to ween people down.
There are other medications for maintenance like buprenorphine and naltrexone. But you can't take those if you're in the throws of heavy addiction, you can die.
The claim that fentanyl death rates are decreasing because fentanyl products are less pure does not make much sense. Even on their provided charts, deaths dropped months before purity did.
The article points to a 50% decrease in purity, which a habitual user would compensate for by taking twice as much. Lower average purity also increases the risk of inconsistent purity, where rare batches are unexpectedly strong and carry high accidental overdose risk. Less pure fentanyl floating around might mean lower chances of unsuspecting non-fentanyl drug users being poisoned with it, but it's hard to see how this could cut into overall overdose cases.
> article points to a 50% decrease in purity, which a habitual user would compensate for by taking twice as much
I’ll be first to admit I’m generally pretty ignorant on this topic but I’ve heard a plausible explanation for how Fentanyl is actually used.
A medical professional shared with me that Fentanyl is too potent to be consumed as is. So generally, dealers use it as an additive. They lace other drugs with trace amounts of to make them more addictive. It’s the MSG of drugs.
So while ODing on say, drug A is possibly with 5 uses at once. When laced with Fentanyl, a person might OD in just 3 uses (because Fentanyl is much more potent than the actual drug the user bought).
Hence, less Fentanyl = less chance of ODing.
> I’ve heard a plausible explanation
To be blunt it was total bullshit. Pharmaceuticals have an extremely wide range of dosages. Fentanyl is on the extreme low end, benadryl an adult might take 25 mg or 50 mg, tylenol an adult might take 500 mg, and something like amoxicillin an adult might take as much as 3000 mg for a severe infection. There are standard, extremely reliable ways to prepare pills that contain the correct dosage regardless of the potency of the pure chemical.
Obviously fentanyl (or its precursor) is imported (ie smuggled) in highly pure form in order to minimize the size of the shipment. Obviously it can't be consumed in that form.
The combination of being potent and cheap to smuggle lends itself nicely to cutting other (more expensive) products with it. That's false advertising but it won't typically kill you in and of itself.
When laymen who don't know what they're doing, don't have access to proper facilities, and certainly can't set up proper quality controls process something that potent it's no wonder that things go wrong and people die. If (for example) the same victims had purchased fentanyl from a pharmacy (as opposed to whatever it was they thought they were consuming) they almost certainly would not have had any issues. Almost no one ODs intentionally.
The point is that it's not "fentanyl is toxic so you OD" it's "the person compounding the pill messed up the dosage, you took more than you thought, so you OD". This could happen just as easily with any other drug. The danger here is due to pills not containing the dosage that the consumer believes them to.
Other drugs aren't dosed in micrograms. It's pretty believable that street labs don't having the precision to get reliable dosing in such small quantities. 50/100mcg is the typical ambulance dosing of fentanyl (where it's often used as the primary painkiller) - so at 500 times smaller than that of benadryl, it would take a reasonably high-end lab (at least by mid-level drug dealer standards) to not wildly mess up the dosing all the time - even if you mixed at larger scales, that still doesn't easily guarantee a uniform blend.
It couldn't happen "just as easily" with any other drug.
Fentanyl isn't too potent to be consumed as-is, but the dosage is very very small. The amount of fentanyl that will kill you is literally invisible. The LD50 appears to be well under 0.01mg/kg (that is, a milligram will kill a 220lb person).
British Columbia declared the toxic drug crisis an epidemic in 2016, with the amount of deaths amounting to 6-7 a day through this period until now.
The article's theory is compelling but given the incredible amount of deaths, thousands upon thousands of deaths in BC alone, I wonder if the rate of death is declining simply because we're running out of people to kill with our indifference.
Killing addicts more quickly than creating new ones would indeed eventually lead to a decrease in drug related deaths. I would really believe this because I know of multiple people that died from ODs in a fairly short window 4-5 years and that spans a range of about 12 years of people. As in to say everyone I know age 24-36 about half of those people that were opiate users died from about 2019-2023 due to fent. All of them that I know the details of were from fake pills too, so very much related to fentanyl.
Long term you couldn't kill more than existed, asymptotically the maximum number of ODs per unit time would be exactly equal to the number created, impossible to be more.
> running out of people to kill with our indifference.
I wouldn't call it indifference. It's the drug policies that we've very intentionally adopted in the west that result in people purchasing from the black market. It's about as indifferent as the deaths due to denatured alcohol poisoning during prohibition when the additive was silently switched.
What happened to the theory that the deaths were decreasing because we burned through our buffer of people susceptible to deaths of despair? That always seemed reasonable to me.
well if you read to the end of the article you might find out.
If the cost didn't go up, it can't have been a supply shortage. Even at its US peak, there wasn't much of a "fentanyl epidemic" in Mexico either.
The overprescription of opioids in the US (especially in the past) is hardly a secret.
“Even as quality worsens, prices in drug markets are sticky, so the decreasing potency probably meant people were taking less fentanyl.”
Perhaps the closure of the southern border a year ago might have played some role in this.
So, statistics clearly show that limiting drugs supply actually works, unlike what the hard left has been saying to us (backed by social “sciences”) since the 2000s?
If we just listened to common sense instead of these people, society would be saved from a lot of pain.
The reporter rightly queried other researchers about this article, and all of them were skeptical that a "supply shock" could be the cause, or even the main cause. My own skepticism is because the death rate went down many months before any sign of shortage appeared.
I haven't read the paywalled Science paper, but The Economist extracted a graph which shows that the purity of Fentanyl pills was stable till the first months of 2024, then dropped sharply. The purity of the powder peaked in 2023, then went down in 2024, back to its older levels. They suppose that it proves the supply was short, but another researcher even states that the supply of Fentanyl precursors didn't change until the end of 2024.
Anyway, the epidemic plateaued by the start of 2022, then went down after August 2023; Source https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
Why did the death rate slow down for one year, then go down many months before any sign of supply changes?
The article says that deaths peaked in mid 2023. Narcan was approved for over the counter use in March 2023.
That suggests a plausible alternative cause.
What is your supposition here? That addicts are keeping narcan around just in case? That good friends of addicts are standing by with the spray in case it is needed? That your local opium den had staff with it on hand?
Narcan should be available, but short of a few users that know they need to keep it around, I don’t buy that making it available has meant a significant change in total outcomes because of timely deployment.
Yes to all of the above. I knew of addicts who managed to get their hands on it many years ago when it required a prescription. Most weren't that resourceful though.
First responders would carry narcan or equivalent. I am sure it is readily available in areas where people are dying daily from overdoses.
Some of those ... absolutely, yes?
You might have got some at a rehab centre, or someone might live with a non-addict friend or partner. Community outreach workers (in cities that have embraced this stuff) might carry some around to administer.
I would be surprised if widespread availability to Narcan didn't decrease ODs.
I would postulate that people learning how to more safely handle and dose fentanyl would be the biggest reason for ODs to drop.
How would you explain the increase in hospitalisation, Emergency Services deployments, and fentanyl drug purity in Q1 2025 then?
Sudden unlearning of aquired knowledge seems unlikely.
See: Figure 1 graph set page 4 - https://www.science.org/action/downloadSupplement?doi=10.112...
Changes in purity, especially when unknown to users, is going to affect hospitalizations and such no doubt, but the people using it also adapt to the purity of a drug over a longer timespan.
Even if people wanted to its not like they can all just bring a sample of their old heroin and a sample of their stronger high fentanyl laced heroin and test their purity and calculate dosages. Which is part of the problem of the war on drugs, many methods of harm mitigation and recovery are barred from users and 90% of their drug information is based on hearsay or personal experience.
> part of the problem of the war on drugs, many methods of harm mitigation and recovery are barred from users
That is a problem for the US, sure. Australia, where I live, has supervised shooting galleries and more of an addiction as health issue approach.
That said, if you had a chance to look at the US graphs linked above - there was a plateau period of high deaths in the US of some three and half years showing no much evidence of users learning to "safely handle and dose fentanyl" followed by a sharp decrease in deaths that corresponds more with a change in policy than an increase in user knowledge.
I would suggest this may be a somewhat more complex and multivariate issue than your initial upthread postulate acknowledges.
I thought this was already well-established public information? That fentanyl came mostly from China was never in doubt, what people were arguing about was whether this was happening with the tacit approval of the Chinese government. Then in 2023 China cracked down on it, and supplies dried up. Whether that was because it was a big enough issue to get their attention, or it was on purpose and they decided it was no longer serving their interests I suspect we'll never know, but I definitely read multiple articles in 2023 about the fentanyl crackdown in China.
Biden era cooperation with China on the issue was at the heart of this.
It wasn't about the direct supply of Fentanyl, or even (by that stage) the direct supply of Fentanyl precursor drugs .. (that gangs used to industrial shed chem lab into Fentanyl) ... this was cutting back and limiting bulk supply of the precursor precursors to shady onselling networks to starve the labs.
Was going well (as per the paper) until US / China relations went in the toilet.
Some of this is covered in The Hidden Cost of Trump’s Trade War on China (March 18, 2025) - https://www.nytimes.com/2025/03/18/opinion/trump-china-trade...
written by a former deputy assistant secretary for US international narcotics and law enforcement affairs.
ADDENDUM: 20 page PDF of data, graphs, suppleentary material from the original 8th January 2026 Science paper
Did the illicit fentanyl trade experience a supply shock? Kasey Vangelov et al (doi/10.1126/science.aea6130)
here: https://www.science.org/doi/suppl/10.1126/science.aea6130/su...
Different articles confirming this with multiple approaches and data points
https://www.npr.org/2026/01/08/nx-s1-5661523/biden-made-big-...
https://www.psypost.org/sudden-drop-in-fentanyl-overdose-dea...
Mexico also began enacting extremely heavy handed tariffs against China and other Asian exporters like South Korea, India, and Vietnam in 2023 onwards [0][1][2][3] in order to protect their domestic manufacturing capacity against an export-driven supply shock, which hit Mexico really badly in the 2000s [4].
> Was going well (as per the paper) until US / China relations went in the toilet
Yep, but as long as Mexico continues to enact trade barriers to protect against an Asian export shock, the APIs needed for synthesis will remain difficult for organized crime to acquire.
Already, cartels have begun tariff arbitraging by targeting the CEE and the Balkans as a new base for synthetic opioid operations [5][6][7], especially because Romanian [8] and other CEE gangs had been collaborating with Mexican organized crime on financial and human trafficking crimes in Mexico for over a decade now.
[0] - https://www.whitecase.com/insight-alert/mexico-imposes-tempo...
[1] - https://www.whitecase.com/insight-alert/mexico-reinstates-ta...
[2] - https://www.whitecase.com/insight-alert/mexico-proposes-sign...
[3] - https://www.whitecase.com/insight-alert/mexico-formalizes-an...
[4] - http://international-economy.com/TIE_Sp03_Rosen.pdf
[5] - https://www.europol.europa.eu/media-press/newsroom/news/larg...
[6] - https://balkaninsight.com/2024/07/24/fentanyl-central-europe...
[7] - https://www.brookings.edu/articles/the-foreign-policies-of-t...
[8] - https://www.occrp.org/en/project/how-a-crew-of-romanian-crim...
That absolutely played a part also.
The biggest takeaway that deserves stressing over and over again is that Things Take Time .. it generally takes 18 months and longer to substantially impact global flows.
The work has to be put in early, kept up in practice, and results are often credited to political actors down the road of time.
TTT - Piet Hein - https://www.circlepublications.net/grooks
Absolutely!
People are always talking about this precusor from China, but I have no idea what this precursor is. Are they chemicals that are useful for lots of things or is it only useful for this? Because if it is the former, then China is just selling regular ass legal chemicals because they are the worlds number 1 supplier of manufactured goods.
Fun fact: The "traditional" way of making it was extracting piperine from black pepper and reacting that with nitric acid. Nowadays it's made in other more industrial scalable ways.
https://en.wikipedia.org/wiki/Piperidine#List_of_piperidine_...
But yes, the same base precursors (and their siblings) are used to manufacture ADHD meds (ritalin/concerta), antidepressants (paxil), insect repellents (picaridin/bayrepel), hair loss medications (rogaine), allergy meds (claritin), anti-psychotics (haldol), anti-diarrhea meds (imodium), and many others. And also PCP.
So it's non-trivial to prevent. The core of the issue is that the one pot Gupta method came about in the 2000s and it made it extremely easy to manufacture fentanyl using these basic building blocks for so much of the pharma industry. Not only just making it easier to source ingredients but it took out all the steps and made the process easy as hell as well.
The challenge in international drug operations was not to get China to stop selling bricks to house builders to but get China to cooperate in stopping the sale of bricks to groups that only use bricks to throw through windows and at heads.
No, it was in doubt.
Now fentanyl is produced from readily available precursors in Mexico. In underground labs: https://www.nytimes.com/2024/12/29/world/americas/inside-fen...
Fentanyl is so potent that just one lab can easily satisfy all the US demand with it, around 10kg a day. That's also why it's ridiculously hard to fight, one smuggled barrel of pure product can supply the entire US for months.
So no, there is no "supply shock". There's just more free Narcan (naloxone).
Cocaine death decreases is the hard thing to explain with either theory, supply or naloxone. Fentanyl supply doesn't affect cocaine in any way and naloxone doesn't work on a cocaine OD.
Maybe some percentage of cocaine deaths are misattributed fentanyl deaths?
I also wonder if there's any link to the Oxycontin reforms. Perhaps now that prescription is reigned in, we are seeing a lot fewer oxy->fent cases which has cut back on the deaths.
Or maybe it's actually that the drug dealers have gotten more careful. Drug dealers don't want to kill their clients, so maybe they've been purposefully diluting to make sure they get repeat customers.
> Perhaps now that prescription is reigned in, we are seeing a lot fewer oxy->fent cases which has cut back on the deaths.
This is definitely part of the story. When your primary source of new addicts is prescription opioids and you cut down on the prescriptions then over time, as people die off from OD, then the OD rate is bound to drop.
The most tragic part of it, to me, is that it's usually the people who got clean who eventually OD. Once they've been clean for a short time then their tolerance for the drug drops drastically, then if they break down and do "just one dose" they make the fatal mistake of thinking they can still handle the same amount they were used to doing before. This exact scenario happened to multiple more or less close acquaintances of mine, even people who were aware of tolerance and should have known better. I'm fairly sure that it's extremely common.
This theory predicts a significant decrease in addiction rates. Is there any evidence of that?
I believe they're using CDC data, which states:
"Drug overdose deaths may involve multiple drugs; therefore, a single death might be included in more than one category when describing the number of drug overdose deaths involving specific drugs." https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
Someone who overdosed after taking cocaine contaminated with fentanyl would be counted as a cocaine ODD.
The Oxycontin "reforms" caused the fentanyl crisis to begin with. People often moved onto heroin and fentanyl because pharmaceuticals were no longer accessible. The massive spike in overdose deaths begun after the decline in opioid prescriptions. See the Opioid Prescriptions & Opioid Overdose Deaths graph here https://drugabusestatistics.org/opioid-epidemic/
In Europe the per kg price of cocaine has apparently halved.
If that's the case in the US as well, it could be that as a result there's more cocaine in the cocaine and fewer adulterants.
People don't have the money to buy drugs, deaths go down and price as well (albeit slower).
For addicts, the drug is the last thing they cut back on when money is tight.
Pure cocaine overdose deaths are relatively rare. Only around 5% of cocaine deaths involved pure cocaine, it's almost always mixed with something else.
> I also wonder if there's any link to the Oxycontin reforms. Perhaps now that prescription is reigned in, we are seeing a lot fewer oxy->fent cases which has cut back on the deaths.
Prescription pills have been a non-issue for a decade by now.
> Or maybe it's actually that the drug dealers have gotten more careful. Drug dealers don't want to kill their clients, so maybe they've been purposefully diluting to make sure they get repeat customers.
Yup. I think that's exactly it.
The major reason for fentanyl deaths was not unintentional overdose because of poor pill quality. It was way too easy to end up with 1mg instead of 500mcg during pill mixture preparation. So _reducing_ the amount of fentanyl per pill results in a better safety margin. And users can just smoke another pill if one pill was not enough to get high, after all.
And yeah, it's just possible that the more reckless drug users are just dead by now. But to be clear, it's still absolutely horrible. We're still above the 2021 level.
So presumably Venezuela is not a factor, as the administration claimed?
Of course it isn't.
Trump said it's about the oil himself.
https://www.dropsitenews.com/p/trump-maduro-venezuela-darfur...
"Supply shock" might not be the only, or even primary cause. As far as I know fentanyl is still widely available and inexpensive.
My guess is only a subset of the population is willing to both A) Use a substance like street fentanyl with known lethality. and B) Do so in a risky and unsafe manner (alone, no narcan, shooting instead of smoking, etc. etc.).
That subset of the population has already been decimated to the point we are seeing a decrease, and survivors have become more educated on how to use without dying.
I'm skeptical of that last one.
My dad was a heroin addict, and while he eventually got (mostly) clean, he wryly joked to me once "you know there aren't a ton of old heroin users for a reason"
Using street drugs kills - we can put people on opiates if done in a controlled way, for the rest of their lives, we instead have gone down the road of prohibition, closing off pathways for people to get maintenance dosing of opiates.
A major factor is Narcan being far more available and usable by people who are not trained.
Is there a graph of the decline in overdoses with time?
Your explanation suggests an exponential decay (ignoring aggravating conditions, like seasonal temperature, violence, ...)
In the article, yes. https://d9258mdc7ql01n.archive.is/C0Y0G/696eb2f917764f004c5f...
> fentanyl powder and pills were losing potency just as overdose deaths were falling
Combined with the already dead, does this not explain things?
Illegal drug suppliers don't make money by killing their customers. Consequently, they finally got control over the potency throughout their supply chain.
Although, I'm more interested in the standard deviation of the potency than the absolute value of the potency. I suspect that is much more correlated with OD deaths.
Just a different form of supply shock - to the supply of users.
Living in downtown SF for the last two years has made it painfully obvious those using fent on the streets are not long for this world. It'd an inherently self-solving problem, grim but true.
There is also a never ending supply of destitute and destined-to-be-destitute in America. The people may change but the problem persists.
Not all (probably not even most) destitute people become opiate addicts. People become destitute because they are opiate addicts, it's not the other way around.
> to the supply of users
I think there is a word for this...
That seems the most plausible explanation.
The article says something along these lines. Every pandemic has a peak point when people become alarmed, and there is a clear way to avoid contamination.
It happened with AIDS when people began stopping having risky relations. It is only natural that it would also happen in drug addiction when everyone sees its devastating effects.
The same thing might be happening to tobacco and alcohol consumption.
Deaths for lack of vaccines (e.g. measles) will also behave the same way. When people see very explicitly that risky behaviour has consequences, they think twice before doing it.
> When people see very explicitly that risky behaviour has consequences
With much emphasis on the "very explicitly" part.
It seems to only work that way when it is very explicit and rapid consequences. Abstract consequences far in the future are not very effective at deterring [ entertaining | desirable | fashionable | profitable ] behavior.
"The same thing might be happening to tobacco and alcohol consumption."
I believe the data on smoking was the opposite. Showing people the terrible consequences of smoking (including very graphic images) turns out to have minimal or no effect. There was a large randomized trial in the pacific northwest some decades ago. A lot of people now point to taxes as the main driver in the decrease.
And when supply catches up, overdoses will spike because addicts tolerance will have decreased.