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>> to discuss the phenyl crisis in the u.s. is dr. jeffrey singer, a health policy study senior fellow at the cato institute. dr. singer, thank you for being with us. guest: thank you for having me. host: let us talk about your background both as a practitioner and also as a health policy researcher at cato. guest: i am originally from new york as you can tell from my accent. but i lived in arizona and i've been practicing as -- for about 40 years and i am also a senior fellow at the cato institute where i work at the department of health studies.

it is a 501(c)(3) nonprofit and nonpartisan, libertarian think tank that the public policy proposals based on the principles of individual liberty, limited government, free markets and peace. i work in the health policy space. host: much of your research has focused on the fentanyl epidemic. where are we in this public health battle? guest: well, if the research is holding, we are not anywhere close to seeing things get significantly better. a study came out by the university of pittsburgh school of public health published in 2018 where they got data from the cdc going back into the 1970's. what they demonstrated was looking at the data was that the overdose rate from nonmedical use of drugs has been on a steady and exponential increase trend since at least the late

1970's. the only thing that changed is that different drugs are predominating among those drugs that are the principal cause of overdose deaths. an example in the early 2000's, the principal cause was diverted prescription plate -- pain pills and then recreational users like to use, and then as the policy establishment and the political establishment wrongly blamed it on doctors overprescribing prescription pain pills and clamped down on prescribing, which prescribing levels are now in 1992 levels, people are migrating to heroin. and then heroin got mixed in with fentanyl and now it is fentanyl and we will see what is next. it has been on a steady increase. it spikes during the covid pandemic along with alcohol and other substance use is. there were a lot of factors

involved including the fact that because of closures and supply chain issues it was difficult to ship opium, which is processed into heroin. so the drug trafficking organization switched out to fentanyl which they can synthesize easily and it is more potent and potentially more deadly than heroin. that also contributed to the spike. now that the pandemic has passed and we are starting to see an eb in the rate and we are seeing a return of heroin into the drug supply. that might be contributing. we have also seen a lot of states and federal policies start to accept harm reduction strategies which will help reduce deaths. but we are still just at under 100,000 a year, which is amazingly high. and, if we continue our restrictionist doubling down on the drug war and i expect that it will just continue either at the same level or at a 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 a derivative naturally from the opioid -- opium plant so codeine and morphine. opioids are opiates chemically modified to get a certain desired results. for example, oxycodone or vicodin. these are opioids. they use the original, natural substrate of morphine and they make the additional molecules and they add additional molecules to get a desired result.

those are called semi synthetic opioids because they have some of the natural part. and then there are completely synthetic opioids that do not require the plant at all and they can just be made in a test tube. fentanyl is one of them. they have been around since the 1970's. it is a very important drug. it rapidly reduces pain and wears off quickly. we use it in anesthesia. if anyone has had a gentle and a static or a procedure where they had intravenous sedation, they likely received fentanyl. we give it to patients in the recovering rooms and intensive care. and we also have fentanyl skin patches. we have been giving to those -- we have been giving those to patients for decades where you put a cat -- a patch on their skin and a small dose slowly gets absorbed and reduced as a requirement for oral pain pills because you have that in the

background supplementing any pain pills. it is a useful drug. there also fentanyl analogs which are modifications. slightly different. there are a few of them that we use in the medical field, mostly in anesthesia. now, in -- just like methamphetamine, which is a legal prescribed drug developed to create -- to treat adhd and the brand name was -- is still prescribed occasionally even though adderall is more popular. but, like that, fentanyl can be made in the lab in an underground lab and sold on the black market. so, that is why it is important to distinguish between fentanyl and illicit fentanyl. host: our guest for the next 35 minutes or so is dr. jeffrey

singer, a health policy study senior fellow at the cato institute joining us for a discussion on the fentanyl crisis. if you have a question or comment you can start calling him now. the lines are regional. if you were in the eastern or 202-748-8000 central time zone 202-748-8000,. -- in the central time -- dr. singer, you mentioned the -- that it can be made, the illicit version can be made chemically. once it is made, how does it get into the u.s. legal or illegal crossings, and which borders are we looking at? guest: first of all, it is very easy to synthesize and once it is made according to data from

the government, roughly 90% is smuggled in by legal u.s. citizens or residentss, mostly in cars or trucks through illegal border crossings. not through the illegal entry points. and it does not just come in through the southern border crossings, it comes in through the airports and through the mail. it occasionally comes in through the northern border crossings. it is so powerful and that is why it has gotten popular for drug trafficking organizations to use. a very small amounts cannot be hidden very easily. most dogs at border crossings are not able to smell fentanyl so it is easy to smuggle through. a lot of people think that the illegal migration across illegal border crossing areas, that is related to this. that is actually a mistake. like i said, the government's phone data comes in legally.

and think about it, if you are in the drug trafficking business it makes more sense considering the billions of dollars that this brings you for sales on the black market, it makes much more sense to pay a hansoms to some u.s. citizen who will 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 you know is trying to maybe migrate up to the united states through central or south america or elsewhere and put some of it in their backpack and tell them when you get across 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 fentanyl originally 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 coming from a lot of other places. we are seeing the made in india. the drug stations have reports of this that they are coming from parts of southeast asia. just recently we learned that they are canadian "super labs" making fentanyl directly, the precursors and the fentanyl. most of them 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 that when you have drug prohibition, the opportunity to make money. this is not, people seem to talk about it as if drug trafficking organizations are south of the border launch missiles into the united states that explode and release fentanyl. they think they are looking around to go into people and kill. they are sending pit fentanyl

and poisoning our country. we have drug prohibition and just like alcohol prohibition, as long as there is a market and people who want to buy it, the market will be met. and there is a term we use in the policy world called the iron law of prohibition which is harder the enforcement the harder the job. prohibition incentivizes drug traffickers to come up with more potent forms that are easier to smuggle in smaller sizes. and once you have taken that risk you can subdivided into more units to get morebang for your buck. during alcohol prohibition they were smuggling in whiskey. in fact, there is a real-life example of the iron law of prohibition probably happening yesterday during the super bowl. when people are tailgating at football games they are drinking beer and wine in the parking lot but you are not allowed to bring alcohol in the stadium. most people do not smuggle in beer or wine but they do it with the hard stuff.

it is our drug war that is making this happen. so when the source of prescription pain pills that the traffickers realized -- fentanyl started appearing in heroin around 2012 and gradually increase. this generally starts in the eastern part of the u.s. and works its way west because most of the heroin smuggled in was called white powder from places like afghanistan and asia. that is easier to mix fentanyl in with rather than the heroin south of the border is black tar heroin and that is more difficult to mix. that is why its made its way and in that direction. by the time covid hit they were supply chain problems. the ingredients to make heroin,

because you have to convert morphine antiheroine. and you need acetic hydride and there is a backlog. that is used for other things like making aspirin. and it was also getting difficult to ship will be around the world -- opm around the world because of the border closures. so, the cartels switch to fentanyl because that was easier to make and as an abundant supply and then during the pandemic, that was almost exclusively the opioid smuggled in. so many nonmedical users of lettuce a heroin were not thrilled that they were getting fentanyl because it is a different experience but they had a dependency and they took what they could get. over time their taste would change and they would like fentanyl. now that those problems have abated, we are starting to see heroin reappear because we have

a very healthy black market and if there is a demand, the demand will be met. there was just a report a month or so ago that we are seeing a boom in heroin again in the united states. host: we have callers waiting to talk. we will start with jim in texas on the line for impacted by the fentanyl crisis. good morning. caller: good morning. i just want to start out, people might be surprised that whether you are prescribed opioids for chronic pain or whether you are a recreational user, the rate of developing severe opioid use disorder is about 7%, regardless of which of the population you are a part of. so i think that most people think that if you use opiates even one time you are probably going to turn into an addict.

the other thing is i mean, we have created a crisis -- the fentanyl crisis because it started out with trying to reduce prescriptions and then the rescheduling of hydrocodone and things like that. if 8.5% of the adult population suffers from chronic pain, that has a huge impact. there are a lot of people out there who unnecessarily go to illicit drugs like heroin or fentanyl, simply because it has become unaffordable to go through the rigmarole of getting a pain management doctor. driving -- i am driving to a pain management doctor right now. i have had chronic back pain for decades and it used to cost me about $300 a year, everything, doctors and prescriptions and whatnot to adjust for my chronic pain.

now it is costing over $100,000 a year. now i do not pay all of that. the v.a. covers most of that. so i would like to have your comments on that. and what is the solution? do we reschedule the drugs? i do not think we make them all legal but i would love to hear what you have to say. guest: thank you i want to correct you about the addiction rate. this is government data and you can catch out my blog post and i have written about this a lot. according to the substance abuse and mental health services administration, which conducts the national survey on drug use and health, they have been tracking the addiction rate to prescription pain pills for example for adults aged 18 and over since 2022. and the addiction rate for prescription pain pills has never been higher than 0.8%.

the population is growing so 0.8% become a bigger number but it is never more than that. they have also tracked that for heroin and other opioids. it is all less than 1%. i know you're not supposed to say that because they have had a lot of movies on hulu and netflix suggesting that that is not true. go to the website of the national institute of drug abuse and find out for yourself. and will play use -- opioid use disorder is a broad term. addiction comes under that umbrella and it is defined as compulsive use despite negative consequences and you see that with alcohol use disorder and gambling addiction. even though you want to stop, it is an underlying compulsive behavior disorder which makes you continue to do it and you know it is harming you. also under the umbrella is dependency which is a completely different thing. opioids are a kind of drug that

when you have taken them steadily for a couple of weeks then your body adjust physiology -- physiologically. stop taking it, you go through a withdrawal reaction. that comes under opioid use disorder as well, but you don't have the addiction. i had some who became -- i had some patients who became dependent on opioids intravenously. but they never craved it. they never felt like they needed it again. other drugs, including antidepressants, beta blockers, which are commonly prescribed for high blood pressure, if you abruptly stop that and you've been on it for a while, you can actually get a fatal withdrawal. you can have a stroke or a heart attack. dependency and addiction are two different things. as far as the pain management is concerned, unfortunately, because our policymakers have long concluded that this is for

treating pain, to be honest, there have been some dishonest doctors out there using their medical degree to sell prescription, and, you know, some of them are 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 prescriptions 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. so anyway, because of that, doctors have been put under pressure by law enforcement, by state laws, and they are afraid to prescribed pain pills now. and in fact, the latest data shows we are now prescribing at a below 1992 level. back in the days when the national institute on drug abuse was urging us to prescribe more, because they said we were under prescribing. and the overdose rate, of course, has gone up.

so a lot of pain patients, not only have we not help the overdose raised by doing this, but we've made a lot of pain patients afraid they will get a visit from law enforcement, some of them in desperation going to the black market to get their supply, and the dangers of the black market our that you don't know what you're going to get here you may think you are purchasing oxycodone, which is what you usually use, but it may turn out that it is counterfeit and it is fentanyl. that is happening frequently. there are patients committing suicide. a doctor at the university of alabama at birmingham talks 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, that is actually against the law federally. there's a thing called the crackhouse statute that does not allow that. but these two organizations have been operating since the end of 2021, beginning of 2022. they've already reversed more than 1300 overdoses. and these are people who would be dead. now one just opened actually in the state of rhode island that the state government approved,

and the state legislature just approved one, they are working on getting online in vermont. but that is federally against the law. in the previous administration, the justice department exercised prosecutorial discretion and chose not to prosecute. but there's no telling what will happen in this administration. so if you can't make this legal and learn the lessons of alcohol prohibition, then at least let organizations that want to help people minimize the risk of overdose death and the spread of disease like hiv and hepatitis from shared needles and that kind of thing. at least get out of the way of people who want to do that by removing the laws they don't allow that. host: dr. singer, to your point, you're talking about possible solutions. the house has passed the h.a. l.t. act last week that would personally -- permanently classified things like fentanyl

into schedule one. do you think that would help at all? guest: yeah. coincidently, i have an article that went live this morning, and the title of the article is, is the h.a.l.t. fentanyl act delusional or performance art? the fact is, it is both. in 2018, the drug administration organization through a temporary emergency orders that all of these analogues of physical, other than the ones already fda approved that i mentioned earlier, all the other ones will be schedule one, that means no accepted medical use and high potential for abuse, and they are totally banned. you are not allowed to prescribe them or anything. in that order was extended a couple of times by hungers, beta scheduled to expire in march -- but it is scheduled to expire in march of this year. the house passed an act that

would not expire. if they herald this as a big change, that is where it is performance art, because all it is doing is continuing what has been unsuccessful since 2018. in reducing overdose deaths. that's number one. the delusional part i think you already alluded to it, which is you cannot stop it. on top of that, heroin is scheduled one. it is scheduled one since the controlled substance act was passed in 1970. cannabis is schedule one kid we don't see any cannabis in this country at all, right? psychedelics are schedule one. we don't see any of that, do we? the point is, just making it schedule one, you are deluded if you think that is going to suddenly do something. in addition to that, there are other features of the act that will also be harmful. so, for example, it is very difficult if you want to do clinical research trials to see

if they have medical use. we all know cannabis has had you since antiquity. we also know psychedelics can help with addiction, depression, ptsd, but in order to get permission to do research on schedule one drugs, they are highly restricted. this whole fentanyl that. -- this h.a.l.t. fentanyl act recognizes that. there are several restrictions. if you are in the pharmaceutical industry, it is just too much of a hassle. those restrictions are a deterrent for you wanted to do research using those drugs, to see if they can have any therapeutic use. you will just do research and other drugs, so you don't have those hassles. for all we know, i mean, we don't know, one of these fictional analogues that are now schedule one, might be good for preventing overdose deaths kid we will never know.

it will pretty much be impossible to do studies on it. also, the h.a.l.t. fentanyl act extends mandatory minimum sentences to people who are found in possession of these schedule i fictional analogues. and, you know, the research has been clear for decades that mandatory minimum's do nothing to deter drug use or drug doing. it is so lucrative, the risks involved with doing drugs are already baked into the decision drug traffickers make to traffic it, plus none of them ever think they are going to get caught. host: we will go to tina in pennsylvania, lines were impacted by the regional crisis. good morning, tina. caller: hi. not necessarily fentanyl. i lost my sign preventable, lethal dose of oxycontin and some other drug. but i am a pain patient, and i belong to the doctor patient for

them. i want to say there is such a bad = stigma on people such as myself who have to take it. i don't take it to get high kid i'm riddled with metal. i have two bad ankles, bad knees. i've broken them both to two times. the problem i'm seeing is these unconstitutional pain clinics, like with me, i'm allergic to cortizone. i've had i can't tell you how many shots in my back, neck, and knees to cortizone. my doctor made me prove my allergy, which sent me into anaphylactic shock, which i had to go to the emergency room, and i almost died. the problem is, you have these people giving these legal prescriptions, and they are selling them. why aren't we locking them up? because eventually they will kill someone like they killed my

kid. i'm tired of the dea being in the doctor's office with me if you have met with the dea. i save everything, every mri, every ct, everything. i cannot go -- i'm not going to spend the rest of my life laying in a bed because i cannot move. and it just makes me so angry that people that are far worse than me because we have idiots on the street that want to get high. put them in rehab. there are empty prisons all over pennsylvania. don't hand them a needle. get them clean. give them something to look forward to. i know if i ever run out of my medication, i'm not going on the street to look for any. because i'm not an addict. i'm physically dependent to them because of my back, my neck, and my knees, but i'm not an addict. host: we will get a response from dr. singer.

guest: well, first of all well,, i empathize with your problem. part of the problem is we doctors are being pressured by lawmakers to treat pain by other means other than opioids. every state has a prescription drug database now, so if you start prescribing opioids that law enforcement think this too much, all of a sudden, you can get a visit from law enforcement. and pharmacies are just as worried, so sometimes we doctors will prescribe an opioid commander pharmacists won't fill it, because they are worried. a calling from the cato's are burris, two years ago wrote "cops practicing medicine," which i urge you to look into it online, but as the caller was

intimating, this is cops telling us how to practice medicine. if you go to a pain management specialist, they will try everything short of an opioid, and then there's a financial aspect, because that is billable and they get paid for it. i disagree by you saying put them in jail, that is prohibition. that is not going to work. substance use disorder is a behavioral disorder. but some people actually like using drugs. research shows 80% to 90% of people who engage in illicit substances over the age, they begin using them in their mid-20's and out, because when they are under 25 or so, your prefrontal cortex is not developed, so you don't have the executive functions you have as an adult. but 80% to 90% of adults who use illicit drugs don't become

addicted, they don't even become dependent, they just use occasionally, but they love to use. college dorms, certain parties, people would use restriction pain kills -- prescription pain pillows like oxycodone or oxycontin. i don't think it is right to use something other than alcohol. it is alcohol, they don't go to jail, but if it's oxycodone, they do. if you force someone to go to treatment, not only is that doing something about their consent and therefore is immoral, but there's evidence showing that they could actually be counterproductive. we did get a number of people, if you don't want to go into rehab, then you go to the order, your underlying compulsive disorder has not been corrected, so you are still using, but you are using at the dose level that

you remember used to give you the desired result, but you've lost your tolerance because you have not used for several weeks, so you are more prone to overdose. also the research shows 80% to 90% of people who have addiction to these drugs began using when they were adolescence, when their brain was not fully matured. so we get into two separate issues, adults versus minors. i don't think you should put an adult in a cage because they chose to use something other than alcohol. to get a buzz. i think that is their personal decision. just like with alcohol. don't get behind the wheel of a car if you could jeopardize others. especially if you're using in the privacy of home with friends. that is your business. they should not be put in a cage for that. host: we have a couple minutes left, but we have time for one last quick question. we go a mic in massachusetts, line for impacted by physical crisis. good morning, mike.

it looks like we lost mike. we will go to nixon in fort lauderdale, florida. good morning, nixon. caller: good morning. good morning, doc. doc, my wife has lupus. she is on ox, she's on serious pain meds. the doctor prescribed her fentanyl, and she had an allergic reaction that she basically hallucinated, "i don't want to take that anymore." so i told the doctor, all these pain meds you are prescribing my wife, i don't want her addicted to all these medications. is there anyway you can get to the root of the problem of what is causing her to have a flareup? he looked at me as if he don't know anything about what i'm talking about. i asked him, what is your background and studying lupus. he said, i have none.

your wife's case is a rare case. and i'm basically going back to school dealing with your wife. so i basically said, what can we do to take her all follow these pain meds? because i don't want my wife addicted to the pain meds come and when she do have a flareup, i rush her to the emergency room , and they are looking at her like ok, here she comes again, she wants morphine, she wants this, and then she's addicted to these things. what advances have we made in lupus? guest: i'm not a specialist in room of the logical diseases, i'm a general surgeon. i suggest you get your wife to see a rheumatologist. those are medical specialists who specialize in rheumatology, connected tissue diseases, sjogren's disease,

rheumatoid arthritis. in regard to her reaction to the fentanyl, every single drug that exists, some people have idiosyncratic reactions or side effects. a lot of people, for example, when they take opioids, they find that they get nauseated. other people, they don't get nauseated. it is important to understand, and our lawmakers do not come that one size does not fit all. everybody has got their own physiology, their own liver function, their own kidney function. different medications in their system that interact with opioids that had a lot to do with the effect they have, so that the one person, five milligrams may be enough to relieve the pain, and another person may need 10 milligrams of oxycodone. so i really, i could not give you advice regarding lupus, but i can recommend that you get your wife to a specialist, which would be a rheumatologist. host: our guest is dr. jeffrey singer.

he's a health care policies studies senior fellow at the cato institute, also author of the book "your body, your health care," which is coming out >> on thursday, the senate judiciary commiee meets to vote on whether to send kash patel's nomination to the senate for full consideration coming afr initial vote was delayed by one week at the request of democrats on the committee who continue to call for a second coirtion hearing with mr. patel. you can watch the vote live at 9:00 a.m. eastern on c-span th-span now, our free mobile video app or online at c-span.org. >> c-span, democracy unfiltered. we are funded by these television companies and more

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