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guest: well, i am originally from new york as you can probably tell from my accent. i have been in arizona now for 45 years and i have been practicing in private practice as a general surgeon for about 40 years, and i am also a senior fellow at guest: i am a senior fellow at the cato institute. the cato institute is a 501(c)(3) nonprofit, nonpartisan libertarian tank that develops public policy proposals based on the principles of individual liberty, ended government, free markets, and peace. i work in the hells paula -- the health policy space there. host: much of your research has focused on the fentanyl epidemic. where are we in this public health battle? guest: if the research holds we are not anywhere close to seeing things get significantly better.

a study came out by the university of pittsburgh on public health in 2018 where they were able to get data from the cdc going back to the 1970's. what they demonstrated was, looking at the data the overdose raced from nonmedical use of drugs has been on a steady exponential increase trend since at least the late 1970's. the only thing that has changed is that it does for points in time different drugs have predominated among those drugs as the principal cause of overdose deaths. in the early to thousands the principal cause of overdoses was diverted prescription pain pills that found their way into the black market and recreational users like to use. then as the policy establishment, the political establishment wrongly blamed it on doctors overprescribing prescription pain pills and clamped down on prescribing,

which prescribing levels are now at 1992 levels, and the people migrated first to heroin, and then heroin got asked in with fentanyl, and we will see what is next. it has generally been on a steady increase now, despite during the covid pandemic, along with alcohol use and other substance uses, you know, a lot of factors involved there, including the fact that because of border control -- border closers -- closures it was difficult to ship opium, so the traffic going -- trafficking organizations switched out to fentanyl, which they consent -- synthesize easily. fentanyl is potentially more deadly than heroin. now that the pandemic has passed and we are starting to see the overdose death rate, we are starting to see a return of heroin. that may also be contributing. we also have seen a lot of states and even federal policies start to accept harm reduction

strategies, which have helped also to reduce deaths. we are still at just under 100,000 year, which is amazingly high. if we continue with our restrictions, doubling down on the drug war, i would predict it is just going to continue either at the same level or higher level. host: dr. singer, you mentioned some of the causes and not causes for the crisis. remind our viewers what exactly fentanyl is and what we know about how it impacts the human body. guest: first of all, just a little bit of nomenclature. there are opioids and opiates. opiates are derived naturally from the opium plant. so, codeine and morphine are

opioids. opiates that have been chemically modified. for example, the lauded, or oxycodone, vicodin. these are opioids. they use the natural substrate of morphine and make additional molecules to get a desired result. those are called semi synthetic opioids because they still have some of the natural part. and then there are completely synthetic opioids that do not require a plant at all and can be made in a test tube. fentanyl has been around since the 1970's. use it everyday. it is a very important drug. it rapidly reduces pain and wears off quickly. we use it in anesthesia. if anyone has had a general anesthetic or procedure where they have had sedation they likely received fentanyl. give it to patients in recovery rooms postop and even have

fentanyl skin patches. that we have been giving to patients for decades, where you put a patch on your skin over about 72 hours, a small dose slowly gets absorbed, and that usually reduces your requirement for oral pain pills. you have that in the background supplementing any pain pills. it is a very useful drug. there are also fentanyl analogs which are modifications of fentanyl, slightly different, and there are a few of them that we use in a medical field, sleep anesthesia. now, just like methamphetamine, which by the way is a legal, prescribed drug to treat adhd, and the aired -- and the original brand name, we still prescribe it occasionally.

adderall is more popular, but like that fentanyl can be made in a lab. in an underground lab and then sold on the black orchid. so, that is why it is important to distinguish between fentanyl and illicit fentanyl. host: and our guest for the next five minutes or so is dr. jeffrey singer. he is a health policy studies senior fellow at the cato institute. use joining us for a discussion on the fentanyl crisis in the u.s. if you have a question or comment for him you can start calling now. the lines are regional for this. if you are in the eastern time zone it is (202) 748-8000. if you are in the mountain or pacific it is (202) 748-8001. there is also a line, if you have been impacted by the fentanyl crisis you can call (202) 748-8002. dr. singer, you mentioned that

it can be made, the illicit version can be made chemically. once it is made how does it get into the u.s.? and which borders are we looking at? guest: well, first of all, it is very easy to synthesize, and once it is made according to the data from the government roughly 90% is smuggled in by legal u.s. citizens or residents, mostly in cars and trucks, through illegal border crossings. not through the illegal entry points. and it does not just come in through the southern border crossings. he comes in through the airports. it comes in through the mail. it occasionally comes in through the northern border crossings. it is so popular, and that is why it has gotten popular for the organizations to use. a small amount can be hidden very easily.

most dogs at border crossings are not able to smell fentanyl. a lot of people think that the illegal migration across camino, illegal border crossing areas is related to this. but that is actually a mistake, because like i said, most of it comes legally. think about it. if you were in the drug trafficking business it makes much more sense, especially considering the billions of dollars this brings for sales on the black market, it makes much more sense to pay a handsome sum to some u.s. citizen who will then drive it through the border and deliver it as directed to someone on the other side and will not be suspected at all by law enforcement than it is to trust somebody who is trying to maybe migrate up to to the united states through central america or elsewhere and put

some of it in their backpack and tell them, make sure you handed over to somebody. it makes no sense. it is much better business sense to spend that money on hiring people to do it. the precursors to make phenomenal were mostly coming from labs in china, but as pressure is placed on the chinese government to put pressure on these labs that are making the precursors they are now coming from a lot of other places. the drug enforcement administration tells us they are coming from india, myanmar, southeast asia, and recently we learned that there are canadian super labs making fentanyl directly, the precursors and the fentanyl. those super labs are shipping it to drug traffickers in australia and new zealand. but some is coming south of the border into the united states. the point is, you have drug

prohibition the opportunity to make money -- remember, people seem to talk about it as if drug trafficking organizations south of the border launch missiles into the united states that explode and release fentanyl into the air that then goes, you know, looking around for people to go into and kill. that is what they say. they are poisoning our country. no. we have drug prohibition, and just like with alcohol prohibition, as long as there is a market and people want to buy at the market is going to be met, and there is a term we use in the policy world called the iron law of prohibition, which is, the heart of the enforcement, the heart of the drug. prohibition incentivizes the drug traffickers to come up with more potent forms of the drug that are easier to smuggle in smaller sizes and once you have taken the risk you can subdivide so you get more bang for the buck. during the alcohol probation we

were not smuggling in beer and wine into the country, they were smuggling whiskey. there is a real-life example of the iron law of prohibition that happened yesterday during the super bowl. when people are tailgating they are drinking beer and wine in the parking lot. but you are not allowed to bring in alcohol into the stadium. they smuggle in the hard stuff in flasks. it is our drug war that is making this happen. when the source of prescription pain pills that found its way into the black market dried up, users then sold heroin. around 2012 the traffickers realized that if they add a little bit of fentanyl to the hair one it will make it or potent so they can smuggle it in tinier packages. it started appearing in heroin around 2012 and gradually increased. we saw this originally show up in the eastern part of the united states and work its way west because the eastern part,

most of the hair one smuggled in was called white our heroin from afghanistan and asia. that is easier to mix fentanyl in with. the hair one from south of the border his black tar heroin. that is more difficult. that is why it made its way in that direction. i the time the covid pandemic hit there were supply problems. there were ingredients to make her one, because you have to convert morphine, and you need and see they can hydrate, and there was a backlog, which is used for other things, such as making aspirin. it is getting more difficult to ship opium around the world because of all of the border closures due to the pandemic so, the cartels switched to fentanyl because that was easier to make an abundant supply. for a few years during the pandemic that was almost exclusively the opioid smuggled

into this country. many non-medical users of heroin were not necessarily thrilled they were getting fentanyl because it is a completely different experience. they had a dependency and took what they could get. then over time their tastes would change and they started to like fentanyl. now that those problems have abated we are starting to see heroin reappear again because we have a very healthy black orchid and if there is a demand for heroin the demand will be met. there was a report a month or so ago that we are seeing a big boom in heroin again in the united states. host: we have collars waiting to talk with you. we will start with jim in texas, on the line for impacted by fentanyl crisis. caller: good morning. i just want to start out, people may be surprised that whether you are prescribed opioids for pain or whether you are a

recreational user, the rate of developing severe opioid use disorder is about 7%, regardless of which of the populations you are a part of. if you use opiates even one time you are probably going to turn into an addict. the other thing is, we have created the fentanyl crisis because it started out with trying to reduce prescriptions and scheduling hydrocodone and things like that. if you think about it, if a .5% of the adult population suffers from chronic pain, that has a huge impact. there is a lot of people out there that unnecessarily go to illicit drugs, heroin, fentanyl, simply because it became unaffordable to go through the

rigmarole of going to a pain management doctor. i'm currently driving to a pain management doctor right now. i have had chronic back pain for decades. it used to cost me about $300 a year. everything, doctors, prescriptions, whatnot to address my chronic pain. now it is costing over $100,000 a year. of course i don't pay all of that. the v.a. covers most of that. what is the solution? do we reschedule the drugs? i don't think we make them all equal, but let me hear what you have to say. guest: first i want to correct you about the addiction rate. this is government data, and if you could check out my blog post i have written about this a lot. according to the substance abuse and mental service health

administration, they have been tracking the addiction rate to prescription pain pills, for example, for adults 18 and older. since 2002. and the addiction rate, the prescription pain pills for adults has never been higher than .8%. the population is growing, so when a percent may become a bigger number, but it has never been more than .8%. they have also tracked that for heroin and other opioids. it is all less than 1%. i know you are not supposed to say that, because they have had a lot of movies on hulu and netflix suggesting that is not true. but you could go to the website of the national institute on drug abuse and find out for yourself. and opioid use disorder is a broad term. so, there is addiction, which comes under that umbrella, and addiction is defined as compulsive use despite negative consequences.

and you see that with alcohol use disorder, gambling addiction. in other words, even though you want to stop it is an underlying compulsive behavior disorder that makes you continue to do it and you know it is harming you. also under the umbrella of opioid use disorder is dependence, which is a completely different thing. opioids are a kind of drunk that when you have taken them steadily for a couple of weeks then your body adjusts physiologically and if you suddenly stop taking it you can go into a withdrawal reaction. you really don't have this compulsive disorder. i have had surgical patients that were in intensive care for weeks and they became dependent on the morphine they were getting intravenously and we tapered them off over a couple of months to avoid withdrawal and then they never craved it, they never felt they needed it again. there are a lot of other drugs that cause dependency, including antidepressants.

beta-blockers, which are commonly prescribed for high blood pressure. if you abruptly stop that when you have been on it for a while you can have a stroke or heart attack. so, dependency and addiction are two different things. as far as the pain a management issue is concerned, unfortunately because our policymakers have wrongly concluded that this is all the fault of doctors treating people for pain -- and to be honest, there have been some dishonest doctors using their medical degree so prescriptions. some of the more high-profile cases, of course. i don't blame that on the chemical. i blame it on prohibition, because you can make a lot more money selling subscriptions for painkillers then you can taking care of a patient in your office, because prohibition makes it a very lucrative business for people who want to be dishonest. because of that, doctors have been put under pressure by law enforcement, by state laws, and

they're afraid to prescribe pain pills now. in fact, the latest data show that we're now prescribing at below 1992 levels, which is back in the days when the national institute of drug abuse was urging us to prescribe more, because they said we were underprescribing. it's gone up. so a lot of pain patients, not only have we not done anything to reduce the rate by doing this, but we made a lot of pain patients go untreated or be abruptly tapered by their babies or get a visit from law enforcement, and some of them in desperation are going to the black market to get their supply. and the dangers of the black market are that you don't know what you're going to get, so you may think you're purchasing oxy co-don't, which is what you usually use, but it could turn out it's counterfeit and fentanyl. that's happening frequently. also a lot of pain patients are committing suicide. there's been a doctor at the university of alabama birmingham who's been keeping track of

that. hope that answers your question. about that. thank you for asking the question. host: dr. singer mentioned a blog post. you can find his writings on at cato.org. in ohio, the line for impacted by fentanyl crisis good morning, heather. caller: good morning. i have a question. my brother is a fictional attics. even when he does not have it, he feels like he's getting zapped, like if he touches metal. he mutilated himself. even if it had bugs in it. i'm wondering if he will ever be ok again. guest: i feel terrible about what your brother is going through. he may have some underlying psychological disorder as well as addiction to the fentanyl. so it is hard for me to say without being familiar.

with his case. . some people turn to drug use as a form of self medication for whatever underlying mental health condition they have, so that may be part of your brother's problem. it is rare for just using an opioid continuously, i'm not aware of it causing you to develop psychosis. it has not been associated with that. host: let's hear from dennis, also in ohio, on the line for impacted by fentanyl crisis. good morning, dennis. caller: good morning. hey, the reason i'm calling is because trump can do anything he wants to do to try to stop this, but the american people are hooked on illegal drugs. they want it, so they will do anything they can to get it, which, of course, if they can't get it the way they want, our crime rate goes up, and it is just a huge problem.

i don't know how you're going to solve this. he may try to stop stuff coming through the border. the american people want these drugs come and they will do whatever they can to get them. so what do we do? guest: that is right. when we instituted alcohol prohibition, we had a whole lot of people buying from bootleg alcohol, we had a whole lot of corrupt politicians to him that we had crime. -- politicians, we had the growth of organized crime. we cap tightening up the border. this time it was coming through the northern border, canada. finally in 1933, we got smart and said, this is a bad idea, let's make it legal and regulate it. so now, for example, when i go to my drug dealer, which is the nearby liquor store in my area, town, i happen to like bourbon,

and when i go to the aisle that has burden on the shelf, i look at a bourbon bottle that says 45% alcohol, and never enters my mind that they may be lying to me, that has 50% alcohol, it may have fentanyl in it. that is because it is legal. if a teenager goes into that store, the retailer is going to seek i.d. to make sure everyone is 21 years or older, because the store will lose their liquor license. that. is a good way to keep it. . it's a good way to reduce access to young people. so the answer is that we need to end the war on drugs. as long as people are going to want this, a healthy black market will exist, and it will always find a way. you can put walls on borders, you can do all sorts of things, beta sort of like water going downhill in a brook. you can add boulders to different parts of the brook, but the water is going to find its way around the boulders and

trickle down stream, because water takes it downstream. and like i said, the harder you enforce it, the more you are ensuring the fact that something even more deadly and dangerous is going to come around. for example, in the last couple of years, we've all heard that the cartels have been adding the veterinary tranquilizer xylazine to fentanyl, usually referred to as tranq. that's not even an opioid. but you can smuggle it in small sizes. there's another opioid, not related to fentanyl, a category called nitazine by a company called novartis but never brought to market, and since 2019 commit has been making his way to the black market. in 2023, in the u.k., they

reported there's a huge amount of nitazene showing up in the black market. not a lot of labs are aware of it, so they are not testing for it. if it gets too difficult to make fentanyl, the cartels will then move over to nitazene. there will always be something else. my idea, the ideal solution, is to end the war on drugs. these are randomly decided to be illegal. cocaine was legal, it was put in coca-cola up until 1914. in 1914, we decided to make certain types of drugs that early illegal, and that is -- federally illegal, and that is when the problems began. we learned from alcohol prohibition and make it legal and regulate it, that will put the cartels, they are already in multiple lines of work anyway, including money laundering and selling dvd's, smuggling humans, so they will just have to

concentrate on those other industries. just like when alcohol prohibition ended in the united states, the organized crime moved over to things like drugs. that is the real answer. in the short run, if that is not politically feasible right now, at least remove government obstacles to harm reduction strategies. in five states in this country, including texas, which has a huge population, if you wanted to hand out fentanyl to people in your area where you know there's a lot of drug use, to test what you bought to see if there's fentanyl in it, you can be arrested, because that is considered illegal. in new york city since the end of 2021, the city has had two overdosed prevention centers to operate, where people can come inside, they use their drug in a safe environment, get it tested personally. there are people standing nearby to rescue them in case, if they overdosed. well,