The U.S. overdose crisis worsened dramatically with the arrival of synthetic opioids like fentanyl -- now responsible for tens of thousands of deaths annually -- and the problem requires innovative new strateges because the epidemic is unlike others that have struck the nation, according to a new RAND Corporation study.

"This crisis is different because the spread of synthetic opioids is largely driven by suppliers' decisions, not by user demand," said Bryce Pardo, lead author of the study and an associate policy researcher at RAND, a nonprofit research organization. "Most people who use opioids are not asking for fentanyl and would prefer to avoid exposure."

While fentanyl had appeared in U.S. illicit drug markets before, production was limited to one or a few capable chemists, and bottlenecks in production and distribution slowed the drug's diffusion. Law enforcement was able to detect and shut down illicit manufacture to contain these outbreaks.

RAND researchers found that today's synthetic opioid surge is fueled by multiple sources. Mexican drug trafficking organizations smuggle fentanyl into the U.S., and China's pharmaceutical and chemical industries are inadequately regulated, allowing producers to advertise and ship synthetic opioids to buyers anywhere in the world.

While traditional criminal organizations play a role in the spread of fentanyl, the internet also has made it easier to traffic these drugs and to share information about their synthesis.

Overdose deaths involving fentanyl and other synthetic opioids have increased from about 3,000 in 2013 to more than 30,000 in 2018. These deaths have remained concentrated in Appalachia, the mid-Atlantic and New England.

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"While synthetic opioids have not yet become entrenched in illicit drug markets west of the Mississippi River, authorities must remain vigilant," said Jirka Taylor, study co-author and senior policy analyst at RAND. "Even delaying the onset in these markets by a few years could save thousands of lives."

For U.S. policymakers, nontraditional strategies may be required to address this new challenge. The researchers avoid making specific policy recommendations, but advocate consideration of a broad array of innovative approaches such as supervised consumption sites, creative supply disruption, drug content testing, and increasing access to novel treatments that are available in other countries, such as heroin-assisted treatment.

"Indeed, it might be that the synthetic opioid problem will eventually be resolved with approaches or technologies that do not currently exist or have yet to be tested," said Beau Kilmer, study co-author and director of the RAND Drug Policy Research Center. "Limiting policy responses to existing approaches will likely be insufficient and may condemn many people to early deaths."

RAND researchers say that since the diffusion of fentanyl is driven by suppliers' decisions, it makes sense to consider supply disruption as one piece of a comprehensive response, particularly where that supply is not yet firmly entrenched.

But the researchers note there is little reason to believe that tougher sentences, including drug-induced homicide laws for low-level retailers and couriers, will make a difference. Instead, they call for an exploration of innovative disruption efforts that confuse or dissuade online sourcing.

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The study is the most comprehensive document to be published on the past, present and future of illicit synthetic opioids. RAND researchers analyzed mortality and drug seizure data, reviewed existing literature, and conducted expert interviews and international case studies.

RAND researchers examined synthetic opioid markets across the U.S. and in other parts of the world, such as Estonia (where fentanyl first appeared 20 years ago). Canada's experience with synthetic opioids is most similar to that in the United States in terms of its timing, sudden increase in drug-related harms, and regional concentration.

"Problems in parts of Canada are as severe as in the Eastern United States despite substantial differences in drug policy, and the delivery of public health and social services," said Jonathan Caulkins, study co-author and Stever University Professor at Carnegie Mellon University.

A handful of other countries in Europe also have seen synthetic opioids increasingly displace heroin. Their experience is varied and shows a range of directions some future markets in the United States may take. For instance, Sweden developed an online market with fentanyl analogs sold primarily as nasal sprays.

Evidence from abroad suggests synthetic opioids may be here to stay: the study found no instance where fentanyl lost ground to another opioid after attaining a dominant position in drug markets.

Funding for the study was provided by RAND Ventures, which is supported by gifts from RAND supporters and income from operations.

The study: The Future of Fentanyl and Other Synthetic Opioids.