1. Introduction

Fentanyl, a synthetic opioid, is an extraordinarily potent drug that is devastating communities across our Nation. One potentially lethal dose of fentanyl is only 2 mg—less than a gram of sugar. But Mexican drug cartels, who obtain the precursor chemicals from China, package fentanyl by the kilogram – about the size of a cantaloupe. A kilogram of fentanyl has the potential to kill up to 500,000 people (DEA, 2022). As a direct result of the failed border strategy of the Biden Administration, a staggering amount of it is flooding into every American community. In fiscal year 2022, enough fentanyl was caught crossing the border to kill 3.3. billion people – or every American 10 times over (CBP, n.d.).

Fentanyl has recently become known as the “silent killer” because it is frequently being mixed (cut or laced) with other drugs unbeknownst to the buyer. In the U.S., news stories hit the headlines every day announcing another tragic death of a young American who died taking a drug laced with fentanyl. Unsurprisingly, synthetic opioid-deaths (largely driven by fentanyl) surged by over 20% in 2021, killing over 71,000 Americans. The U.S. Department of Health and Human Services’ Substance Abuse and Mental Health Administration estimates that 9.5 million Americans abused opioids in 2020—the latest data available from the National Survey of Drug Use and Health (SAMHSA, n.d.). Total drug overdose deaths since 1999 have topped 1 million (HSOAC, 2022).

The U.S. is experiencing a public health crisis because of the volume of illicit fentanyl that has made it into our country through the southern border. The fentanyl-related deaths are a tragic illustration that every state is a border state—though too few have drawn that connection. Fentanyl is everywhere and Americans need to be aware of its prevalence and the dangers associated with consuming it, whether intentional or not. Therefore securing the border is the most vital step that must be taken to halt the infiltration of fentanyl into communities. Serious, actionable steps must also be taken for stricter prosecutorial measures to disarm the cartels and their couriers, who are making millions of dollars from fentanyl sales. Additionally, the federal scheduling of fentanyl needs to be revisited and state and local educational efforts on the harrowing dangers of drugs need to be amplified. 

2. Dangers of Fentanyl

Through the Controlled Substances Act (CSA), Congress created five schedules to designate federally regulated substances taking into account medical use, potential for abuse, and safety (21 U.S.C. 812). Drugs that are classified as Schedule I have a high potential for abuse, no currently accepted medical use in the U.S., and  a lack of accepted safety for use of the drug (21 U.S.C. 812(b)(1)). At the other end of the spectrum, a Schedule V drug has low potential for abuse, and there is currently medically accepted use for treatment in the U.S. Further, abuse of a Schedule V drug may lead to limited physical or psychological dependence compared to Schedule IV substances (21 U.S.C. 812(b)(5)).

Fentanyl, which was developed in 1959 as an intravenous anesthetic, is currently a Schedule II drug (DEA, 2020). Under the CSA, a Schedule II drug has a high potential for abuse, has a currently accepted medical use in the U.S. with severe restrictions, and abuse of the drug may lead to severe psychological or physical dependence (21 U.S.C. 812(b)(2)). Fentanyl is 50 times more potent than heroin and 100 times as potent as morphine (DEA, 2020). The drug was designed to be fast-acting for non-extended periods of time, and its typical uses included the treatment of extreme pain, usually during or after surgery, or for late-stage cancer pain. In the 1990s, fentanyl skin patches were developed under the brand name Duragesic with the intent of being used as treatment for chronic pain for patients who developed a physical tolerance to opioids (Stanley, 2005). Soon after, fentanyl in lozenge, lollipop, tablet and nasal sprays followed for similar medical purposes (Stanley, 2005).

Consistent with a Schedule II designation, the potential for misuse or accidental ingestion of fentanyl, including prescription, is extremely dangerous. The ease of delivery methods contributes to the potential abuse of fentanyl or other products laced with fentanyl. For example, not long after Duragesic came to the market, reports of deaths due to overdoses of children and animals with patches accidentally stuck to them began to proliferate (PNNL, n.d., Stoecker, 2016). In 2013, the FDA issued a safety advisory requiring color changes to writing on skin patches to “prevent accidental exposure to the patches, which can cause serious harm and death in children, pets, and others. Similar changes are being requested for the generic fentanyl patches,” (FDA, 2013). Janssen discontinued the manufacture of Duragesic on June 30, 2020, yet generic versions of the patches are still produced (Drugs,.com, 2022).

Despite the potential for misuse, only a small fraction of deaths attributed to fentanyl overdoses today involve prescription forms. The relatively stagnant raw number of prescription-related fentanyl fatalities over the past few years seemingly indicates that the safety measures in place in controlled medical settings are generally effective. Instead, the vast majority of deaths involve illicitly manufactured synthetic fentanyl. Of the estimated 107,622 overdose deaths in 2021, 71,238 (66%) were due to synthetic opioids, primarily fentanyl (DOJ, 2022). The percentage of drug overdose deaths involving a synthetic opioid has increased dramatically since 1999 (Figure 1). The Centers for Disease Control and Prevention called the year 1999 the “first wave” of the U.S. opioid crisis because of the rise in prescription opioid deaths (Figure 2). The year 2010 is considered the “second wave” due to the rise in heroin deaths (Figure 2). There was a significant uptick in this percentage in 2013 during what is called the “third wave” of the U.S. opioid crisis (Figure 2). Those totals pale in comparison to present-day as synthetic opioid-involved overdose deaths in 2020 are 18 times higher compared to 2013.

Figure 1. National Drug-Involved Overdose Deaths*, Number Among All Ages, 1999 – 2020

Figure 2. Three Waves of Opioid Overdose Deaths

3. Today’s Fentanyl: Manufactured in China, Smuggled by Mexican Cartels

As explained above, the deadly fentanyl that is plaguing American communities is part of the illicit drug trade that is trafficked over the southern border. In 2019, Customs and Border Patrol (CBP) reported that “a majority of the illicit fentanyl in the United States is manufactured in clandestine labs in China and possesses strong opioid properties that make it an attractive drug of abuse” (CBP, 2019). The Drug Enforcement Administration’s (DEA) data gathering points to China as the origin of nearly all fentanyl trafficked into the U.S. Figure 3 (below) details/ the variety of ways the drug is illegally shipped directly into the U.S. or through Mexico and Canada, where it is then smuggled across the border (DEA, 2020). The high demand for opioids in the U.S. is enabled by cartel-controlled ports in Mexico, and our now unsecure border. This results in an attractive profit opportunity for Chinese manufacturers of illicit fentanyl. To illustrate the high demand, CBP reportedly seized 31 kilograms of fentanyl in 2015, and 1,154 kilograms in FY2019 (Myers, 2019).

Figure 3: Fentanyl Flow to the United States 2019 (Source: DEA)

In recent years, the Mexican cartels have also developed routes from India for some of the precursor chemicals used to make fentanyl (DEA, 2020). Finding new avenues of these materials took on a greater significance for the cartels after the Trump Administration began a pressure campaign on China, including the first-ever indictment of a major Chinese drug trafficker for distributing fentanyl in the U.S. (TWHA, n.d.). After discussions between the U.S. and Chinese governments, China banned fentanyl production in May of 2019, announcing they would regulate all fentanyl-related drugs as controlled substances. As a result, their illicit direct to U.S. market fentanyl trade shrunk significantly during the remainder of the Trump Administration (Newman, 2019)(Feng, 2020).

Those gains were short-lived with the change in administrations. The Biden Administration’s failed border strategy created a new avenue for fentanyl to make its way more easily into the U.S. Now, Chinese manufacturers of the precursor materials send them directly to the Mexican cartels who then produce the fentanyl into pills or lace other drugs with it (CRS, 2022). These substances arrive at the Mexican maritime ports which are notoriously fought over by the cartels, namely the Sinaloa and the New Generation Jalisco cartels (CJNG). Both of these cartels are designated by the U.S. government as transnational criminal organizations (DEA, 2020). For example, the Manzanillo port, a crucial entry point for fentanyl and methamphetamine precursors, is controlled by the Jalisco cartel but is often violently fought over (Wilson, 2021).

Once the Mexican cartels obtain the precursor substances they are then converted into fentanyl, pressed into pills, laced into fake prescription and illicit drugs, and then smuggled across the U.S. – Mexico border along with migrants and other narcotics (Dalby, 2019).

The production of synthetic fentanyl is less costly and easier to duplicate than other narcotics. For example, a cook in a makeshift lab in Mexico can reportedly make enough fentanyl for “hundreds of thousands of doses” every 6 days. The precursor chemicals to manufacture fentanyl are also cheaper – around $200 per kilogram versus $6,000 for heroin (Kamp, et.al, 2022). As a result, fentanyl is highly profitable for all involved in the drug network. For example, a fentanyl cook for the Sinaloa cartel reported an income of $2,500 per week  (Kamp, et.al., 2022). As a comparison, the average Mexican weekly wage is only $35 per week and around $1,860 per year (Yucatan, 2015). DHS estimates that the cartels are now grossing $13 billion a year trafficking drugs and migrants, the equivalent of the revenue generated by the Fox Corporation (Murdock, 2022).

4. How Fentanyl Floods Across our Borders

After fentanyl is produced, the Mexican cartels transport it to the U.S. border through various means, including through the land, air, and sea ports of entry. During the Biden Administration, there has been a noticeable shift in fentanyl going across the southern border between ports of entry while as many as 80% of Border Patrol agents have been taken off the line to focus on processing migrants. According to the federal government, the most popular route for getting illicit drugs into the U.S. is through the Tijuana-San Diego border region. Federal officials consider this area the “epicenter” of the drug crisis because at least 60% of the fentanyl seized throughout the entire U.S. is found in San Diego and Imperial counties of California, which amounted to 5,091 pounds in the first nine months of 2022 (DoJ, 2022). During that same period, fentanyl distribution in Tijuana reportedly rose by 333% in the tourist zone, as Mexican authorities struggle to contain the criminal gang fights, drug trafficking, and overdose deaths (Ayala, 2022).

Fentanyl is particularly attractive for the cartels because it is manufactured at a lower cost per dose compared to other drugs and easy to transport across the border. When fentanyl is cut into other drugs, like cocaine, it makes that primary drug more potent and addictive. This creates fatal consequences when unsuspecting users are not aware of the potency of the products they have purchased because they are laced with fentanyl (CBP, 2019).

The DEA believes that the uptick in fake tablets or "dupes" is fueled by drugs pouring over the southern border from Mexican drug cartels (Kamp et.al., 2022). To illustrate this, CBP seizures of fentanyl went from two pounds in 2013 to over 530 pounds in FY 2017 (DoJ, 2022). In FY22, a record 14,700 lbs. of fentanyl was seized at the U.S. Southern Border – up from the 11,200 seized in FY21 (CBP, n.d.). This is reportedly enough to kill 3.3 billion people – or every American 10 times over (CBP, n.d). To be clear, not all the illicit fentanyl is coming across the southern border. Some enters through express consignment or international mail and reportedly have a substantially higher purity level than the those entering along the Southwest Border (CBP 2019). Unfortunately, these trends have shown no signs of slowing down. In the DEA’s recent four-month nationwide sweep for fake prescription medication, they seized around 10 million pills and nearly a thousand pounds of powdered fentanyl. The DEA Special Agent in Charge stated that this is “equivalent to 36 million deadly doses” (Mackay, 2022). Across the country, our communities are on the frontlines of a drug crisis. 

5. How Fentanyl is Destroying American communities

The rise of fentanyl related overdoses is a recent phenomenon, as this drug was not on law enforcement’s radar a decade ago. In 2018, Rolling Stone magazine elevated the issue to the national stage, writing that 37% of New York City’s cocaine-related overdose deaths involved fentanyl (Scaccia, 2018). Law enforcement in Tennessee subsequently warned communities about marijuana laced with fentanyl. Today, daily overdoses are reported on the news all across the country, and seemingly no town or school appears to be safe. The ‘silent killer’ has claimed the lives of hundreds of thousands this year alone. It's been reported that 136 people die every single day from an opioid abuse in the United States alone (Cerner, n.d.).

The tragic recent headlines speak for themselves. A mother from Fullerton, CA, mourned the death of her 17-year old child, who was found unresponsive after a party (Patel, 2022). A 21-year old was discovered on the bathroom floor by her mother in Nebraska and died from fentanyl overdose in the hospital two days later (Chapman, John). In Buda, Texas, a community gathered to celebrate the would-be birthday of a fifteen year old – one of four students in his school who died from fentanyl this year (Al-Shaikh, Sarah). Another thought he had been taking Xanax or Percocet to help him sleep but unknowingly took a pill laced with fentanyl and died (Flores, 2022). A 15-year old girl in Alabama was found dead in her home after taking fentanyl-laced pills. In Maine, a 14-year old was found dead after ingesting what she thought was cocaine but turned out to likely be pure fentanyl. Three underage children were found dead in a hotel room in Michigan with Fentanyl in their system after an accidental overdose (Russell, 2022)(Kovanis, 2021). In Georgia, the number of young people who died from fentanyl-laced drug overdoses spiked last year by 800% compared with the year before the pandemic (DPH Georgia, n.d.). A common theme in all of these cases is that these young Americans were unaware that the drugs they purchase contain trace amounts of Fentanyl.

The alarming reality is that federal data on fentanyl related deaths likely underestimates the true scope of this crisis. What is abundantly clear is that families and communities across the country are directly impacted by the fentanyl crisis. The prevalence of opioid misuse has caused a historic decline in our Nation’s life expectancy in the past few years (Quast, 2020). The fentanyl epidemic strains law enforcement as increased drug use leads to increased crime. Public healthcare and social services are also overrun, with the CDC reportedly estimating that wrong use of opioids costs taxpayers $78 billion each year (CDC, n.d.).  

6. Cartels Are Intentionally Targeting Young Americans

One of the most alarming parts of the fentanyl epidemic is the prevalence of brightly colored pills and powder – known as “rainbow fentanyl” and has been seized in at least 26 states (DEA, 2022). These new pills look like candy, and some of the drug traffickers have nicknamed them Sweet Tarts and Skittles. The DEA is reporting that it is not an accident or coincidence, but a deliberate attempt by drug traffickers to lure in young Americans and get them addicted at an early age (Sinnenberg, 2022). Other experts have suggested that the colored pills are meant to resemble real prescriptions from a pharmacy (Mann, 2022). As seen in Figure 5, both genuine and fake pills are extremely similar, and could be mistaken by even a regular user

Recent discoveries of fentanyl stored in Lego boxes and sidewalk chalk appear to be methods used to conceal drugs and avoid law enforcement detection (DEA, 2022). While there has been no clear evidence indicating drug traffickers are putting pills directly into children’s candy, many parents were understandably concerned about the safety of trick-or-treating this past Halloween (Snow, Ali, 2022). Polling indicates that at least 64% of parents were reportedly concerned someone lacing their children’s candy with fentanyl or other dangerous drugs this Halloween season (Rasmussen, 2022)

Figure 4: Rainbow Fentanyl seized by the DEA

Source: DEA

Figure 5: Authentic vs. Fake oxycodone M30 tablets

Source: DEA

 There is legitimate cause for concern about the overwhelming evidence that cartels and drug dealers are targeting teens through social media. Drug dealers are reportedly using Snapchat in particular to offer party and study drugs (Vicci, 2022). All too often, these are fake pills that have been cut with fentanyl and, therefore, the potency of the dose is higher than expected. Figure 6 illustrates some of the emoji codes used for fake prescription drugs, such as the kind that are found being laced with Fentanyl.

Figure 6: Fake Prescription Drugs

Source: DEA

7. The America First Action Plan Against Fentanyl

Previous Action Against Fentanyl

Putting a stop to fentanyl deaths must be a top priority for policymakers at the federal and state levels. It also requires a recognition that the fentanyl crisis cannot be solved if the southern border remains unsecure.

In the first year of his administration, President Trump declared the opioid crisis a ‘public health emergency’ and secured a record $6 billion in new funding to combat the opioid epidemic (TWHA, n.d.). At that time, opioid deaths had doubled in the past seven years, and the rate of drug overdose deaths involving synthetic opioids such as fentanyl had increased by 45% since 2016 (NIDA, n.d.)(CDC, 2018). In 2018, a key legislative success shortly followed when President Trump signed into law the “SUPPORT for Patients and Communities Act”  (115-271). This comprehensive law included multiple ways to increase access to treatment and an important a component to stop illegal drugs, including fentanyl, from entering the country (TWHA, 2018). Additionally, in 2018 the DEA temporarily added fentanyl-related substances to Schedule 1 substances under the Controlled Substances Act (Federal Register, 2018). This has been extended seven times by Congress and is currently set to expire on December 31, 2022, prompting bipartisan proposals to permanently schedule fentanyl analogues (HR 6946)(HR 7300)

Strategic, powerful policies that secured the Southern border and targeted the cartels were put in place to stall the drug flow. Enacting kingpin designations against traffickers in China, India, and Mexico meant tougher sanctions on businesses linked to cartels such as the CJNG (DoT, 2020). Pressure from the international community, led by the Trump Administration, was instrumental in China’s banning of fentanyl in 2019. Under these measures, the amount of fentanyl coming over the border remained under 5,000 lbs. per year, compared to the reported seizures of over 10,000 lbs. from the past two years (CBP, n.d.).

Adding to the Toolkit

As the Biden Administration stumbles in its approach to fight the deadly fentanyl epidemic, there are several policy measures that should be prioritized to overcome the tragedy playing out in our Nation’s communities.

5. Securing the Border to Save Lives: Stopping the flow of fentanyl in the U.S. should be the number one priority to end the drug crisis. Right now, the border is controlled by the cartels, and the open border is a magnet encouraging them to smuggle even more migrants and deadly fentanyl into our country for their own profit. Border Patrol agents are overwhelmed with the influx of illegal aliens and need new strategies in place. Specific actions include:
   • Reinstating the Migrant Protection Protocols (MPP), also known as ‘Remain in Mexico,’ which served as a powerful deterrent to illegal immigration by requiring asylum seekers to await their court dates in Mexico.
   • Resuming construction of the border wall system to create a barrier against the deadly flow of fentanyl into our Nation.
   • Getting Border Patrol agents back on the line patrolling the border instead of processing illegal aliens for release into the country.
6. Strengthening Law Enforcement Action Against Cartels: With more money, the cartels are more powerful. They can grow their weapons arsenal and further proliferate the flow of drugs in communities. Strengthening law enforcement will take criminal cartels, their couriers, and dealers off the streets and off social media where young people especially are most vulnerable. Specific actions include:
   • Adding more groups to the Specially Designated Nationals and Blocked Person List, which prevents U.S. citizens from interacting with them.
   • Adding international narcotics trafficking activities of specially designated narcotics group to section (a) 6 of the Global Terrorism Sanctions Regulations.
   • Sanctioning online vendors.
   • Amend Title 28 of the US Code to strip foreign states involved in production and exportation of illicit opioids of foreign and sovereign immunity.
7. Permanently Scheduling Fentanyl-Related Substances as Schedule I: Drugs and other controlled substances are classified, or ‘scheduled’ according to their acceptable medical use and their potential for abuse or dependency (DEA, n.d.). Healthcare policymakers should ensure the scheduling of fentanyl is an appropriate match to the danger it causes.
   • The Government Accountability Office released a report outlining options for the temporary scheduling of fentanyl-related substances (FRS) as Schedule 1 (GAO, 2021).
   • There is bipartisan Congressional support to permanently schedule fentanyl-related substances with a recent example from Reps. Ted Budd (R-NC), Chris Pappas (D-NH), and Tony Gonzales (R-TX) (Office of Congressman Ted Budd, 2022).
   • The Biden Administration’s Office of National Drug Control Policy has supported the policy and the Drug Enforcement Agency director stated: “The permanent scheduling of all fentanyl related substances is critical to the safety and health of our communities. Class-wide scheduling provides a vital tool to combat overdose deaths in the United States.” (WH ONDCP, 2021).
8. Take Action on the State Level:
   • State-led educational efforts built into school curricula can help lower the demand for drugs. Local leaders can advance several initiatives that educate parents or encourage children to volunteer in an addiction center, for example. States should follow the example of Texas’s awareness campaign, called ‘One Pill Kills’ to educate and find creative ways to teach children about the danger of overdosing.
   • States should institute harsher penalties for convictions of fentanyl distribution and related crimes. Local laws regarding drug enforcement protocols should mirror the federal ones, especially if fentanyl is designated at Schedule I.
9. Conclusion

Due to a failed border security strategy, fentanyl is devastating communities throughout our Nation. The problem will only worsen if the Biden Administration continues its ‘America Last’ approach to the border’ and inaction to combat fentanyl. The fentanyl crisis proves that every state is a border state and the trauma experienced by those affected by drug deaths cannot be overstated. A record number of Americans died from fentanyl overdoses and many others are suffering from mental health issues. As a result, the life expectancy for Americans dropped for the first time in 26 years (Scientific American, 2022). Fentanyl is the deadliest drug ever encountered in our Nation’s history. An America First policy to secure the border and defeat the cartels will get fentanyl off the streets and keep American communities safe.