Methamphetamine is back like never before. Much to blame is the opioid policies blunder.
“I cut it twice and it’s still too short” is an old carpenter joke about persistence coupled with incompetence. It’s a really good joke. But there is nothing funny about the persistent incompetents who have caused both suffering and death by adhering to their silly addiction plan by strangling the supply of prescription pain relievers.
It’s now the world’s worst-kept secret that the plan failed on more levels than Super Mario Brothers. But there is always room for “improvement”. So let’s hear it for PROP, the CDC and the DEA to help us deliver two epidemics of of them really dangerous drugs – none of which are medically useful (1) – instead of a much less dangerous class of medically necessary drugs. The deadliest drugs in the United States right now are fentanyl (no surprise) and methamphetamine and they kill now far more people per year than oxycodone or hydrocodone ever made. Going fine.
I have written dozens of times how the difficulty of getting drugs like Vicodin and Percocet (2) Directly leads to a huge increase in heroin use, which created a US market for illicit fentanyl from China starting in 2013. This is indisputable. But, isn’t it too much to blame the recent massive upsurge in methamphetamine deaths on long-standing opioid policies? Not really. And I will go a little further. The fact that methamphetamine has come back in full force is the result of two separate but equally stupid policies, nine years apart.
WHY ARE POLICIES ON OPIO CADES CAUSING AN INCREASE IN METHAMPHETAMINE DEATHS?
A recent history in the Cincinnati Enquirer examined the devastation caused by methamphetamine in the Midwest, particularly in Ohio and northern Kentucky. Writer Terry DeMion reported that several drug task forces in both states saw a 1600% increase in methamphetamine seizures from 2015 to 2018 (Figure 1).
Figure 1. Amount of methamphetamine (in pounds) seized by 23 task forces in Ohio and Northern Kentucky between 2013 and 2018. I added two block arrows. The green arrow points to March 2016, when the CDC released its now infamous guideline for prescribing opioids for chronic pain. The inflection point, where the slope of the line begins to increase (indicated by the red arrow) occurs three months later. Coincidence? You tell me. Source: High Intensity Drug Trafficking Areas of Ohio, Cincinnati Enquirer.
Whether the two arrows on the graph actually relate is open to debate, but the role of (illicit) fentanyl in the return (and then some) of methamphetamine is not. Some reasons include:
- Methamphetamine is perceived to be a safer alternative to heroin and therefore a much safer alternative to fentanyl.
- Some addicts who are addicted to heroin or fentanyl use methamphetamine to wake up or “come down” from the opioid.
- The two drugs are increasingly used in combination, as measured by urine samples (Figure 2).
Figure 2. Between 2013 and 2019, the percentage of fentanyl users (as determined by urine tests) who also consumed methamphetamine (orange line) increased from negligible to almost one-third. The black line represents cocaine and the turquoise line heroin. Source: JAMA network open, January 3, 2020.
- In Ohio, methamphetamine fortified with fentanyl is increasingly common, as measured by analysis of confiscated samples (Figure 3).
Figure 3. Prior to 2016 in Ohio, methamphetamine fortified with fentanyl was rare. Now, nearly 3% of the samples seized contain fentanyl (blue rectangle). Source: Ohio Harm Reduction
And there is this (emphasis mine):
“They perceive (methamphetamine) as different, sometimes even less in a way, thus they underestimate him. But when their batteries are dry, they need to “come down”, what will they turn to? Opiate addicts turn to opiates. “
Dr Mina Kalfas, Certified Addiction Expert in Northern Kentucky. Source: Cincinnati investigator
So, it’s fair to say that the 2016 CDC guidelines were directly responsible for the scourge of fentanyl in the United States and (at the very least) indirectly for the return of methamphetamine use and deaths. The damage caused by CDC guidelines based on the 2016 PROP does not go away. At best, it’s morphing.
WHY IS METHAMPHETAMINE SO CHEAP AND EASY TO OBTAIN?
This one is easy – another clumsy policy. Before 2006 (3), most methamphetamine has been produced by a reaction (called reduction) of pseudoephedrine – the active ingredient in the decongestant Sudafed. This is how the Breaking Bad show began. But the reactions of the pseudoephedrine method give the “chemist” doing the job an unclean mess. The yield (the percentage of the amount of material isolated from the reaction divided by the expected amount) is low, so a lot of Sudafed is needed.
Go into the DEA (and exit the Sudafed) and the next thing you know, the chemists have found another way (called reductive amination) to make meth. New” (4) The method has been called P2P, which stands for phenyl-2-propanone (aka phenylacetone) – the main chemical required for synthesis. Any organic chemist can tell you how easy it is to perform a reductive amination reaction, so it’s no surprise that methamphetamine has become cheaper, purer, and more abundant than it is. was not before Sudafed was kicked off the counter.
I have already written about this (see Dear CDC: What are you going to screw up next? Methamphetamine is back). Here is the result of removing Sudafed from the shelves.
Methamphetamine seizures (pounds) in the United States 2006-2016. Graphic (modified): Sahil Chinoy. NY Times Source: US Customs and Border Protection. The amount of drugs seized increased immediately after Sudafed was taken off the shelves.
And just in case you need more proof, what about that? In 2006, the selling price of methamphetamine in the United States was $ 150 / gram and the product was approximately 40% pure. By 2010, the price had fallen to $ 50 / gram and the purity had doubled to around 80%, all due to the switch to the P2P synthesis method. More meth, cheaper and better (plus a bunch of runny noses – Sudafed PE Sudafed replacement is as useful as a goalie mask in stopping a runny nose). Brilliant.
Let’s sum up:
- As opioid pills become less available, in part due to ill-advised efforts to control addiction, heroin becomes the opioid of choice. Sales boom. The dead too.
- The opioid “problem” becomes a “crisis”.
- With a healthy heroin market in place, fentanyl began to appear from China in 2013. It is easy to synthesize, much more dangerous than heroin, and much easier to transport.
- The “crisis” becomes a “catastrophe” because the worst drug of the street (at the time) replaces heroin or is used to dope it. Deaths are skyrocketing even as prescriptions for legitimate pain relievers decline.
- The fear of fentanyl prompts addicts to seek a “safer” alternative – methamphetamine or to use it to “detox” from fentanyl – a sort of “evil narcan”.
- Methamphetamine-related deaths skyrocket; it is becoming the deadliest drug in parts of the United States.
- Thanks to the Patriot Act of 2006, there is a solid supply of pure and inexpensive methamphetamine.
Could we maybe mess it up worse? It remains to be seen.
In the meantime, thank our elected officials, our state and federal agencies, our justice departments, both state and federal, and the geniuses of PROP (and other academic dilettantes) and their CDC minions in the early 2010s for having helped to create a situation that is by any measure worse than ten years ago. Hope they all sleep well at night.
Or, if they’d rather stay awake, there’s a lot of crystal meth around. It will help.
* Unless stated otherwise, “fentanyl” refers to illicit fentanyl and its analogues, such as carfentanil – not pharmaceutical fentanyl, which is used (in lower doses) for general anesthesia and pain control intractable, often in terminally ill cancer patients.
(1) Fentanyl and methamphetamine are both legal Schedule I pharmaceuticals. What is sold on the street is not.
(2) To be fair, the government cannot be blamed for all of this. Purdue’s OxyContin got the ball rolling and when its abuse-resistant formulation was launched in 2010, the heroin market immediately took off. After that, the anti-opioid movement “took over.”
(3) The Methamphetamine Epidemic Control Act, 2005, which was part of the Patriot Act was enacted by President Bush on March 9, 2006.
(4) The P2P method was not new. It has been used in the past to make methamphetamine, but the chemicals needed for the P2P method were beyond the reach of backyard meth labs. Sudafed was an easier starting material until it was controlled. Then the P2P method came back in force.