Recent Issues Related to Illegal Drugs in the United States

In January 2025, Donald J. Trump assumed office as the 47th President of the United States of America (hereinafter, "America"). One important policy implemented by President Trump has been the regulation of fentanyl smuggling. As part of this effort, he has called on the Chinese government to take stronger enforcement measures, as he presumably identified China as a primary producer and exporter of fentanyl. Trump threatened China with additional tariffs as leverage to curb the flow of the drug.

Why is fentanyl so devastating? The answer lies in the sharp rise in overdose deaths linked to illicitly manufactured synthetic opioids, including fentanyl, in America beginning around 2013. According to available data, deaths from opioid overdoses increased from 25,052 in 2013 to 81,806 in 2022. During the same period, total deaths from drug overdoses rose from 43,982 to 107,941. The numbers for 2023 show a slight decline to 79,358 opioid-related deaths and 105,007 total drug overdose deaths. Nevertheless, the figures remain alarmingly high. This so-called opioid crisis has been particularly pronounced in the Appalachian region, with West Virginia and Tennessee standing out. In 2022, their drug overdose death rates per 100,000 people were 80.9 and 56, respectively. Notably, the epidemic is unfolding in the Rust Belt, the very region that forms a core part of President Trump's political base.

The origins of the opioid crisis in America can be traced back to the 1990s, when opioids began to gain acceptance as a mainstream component of medical practice and treatment. Prior to this period, opioid use was strictly restricted. Physicians and nurses typically administered only minimal doses of opioids to patients, unless death was imminent.

This perspective shifted when researchers and specialists concluded that existing treatments for chronic pain were insufficient. In 1996, the president of the American Pain Society went so far as to declare pain the fifth vital sign; in other words, the measure of pain is as important as heart rate or blood pressure. This declaration prompted researchers and physicians to encourage healthcare providers to prescribe opioids more liberally in order to better manage the pain experienced by patients. As a result, opioids became a standard component of pain management, and their widespread availability in the market led to pervasive overuse among patients. In the Appalachian region, the crisis has been further fueled by economic decline, the collapse of the coal industry, and the ensuing situation known as Appalachian despair. This environment has contributed to a pattern in which middle-aged white residents, grappling with daily anxieties, turn to substance use in pursuit of relief. This has ultimately resulted in high rates of overdose.

Compounding this situation is a system that facilitates drug overuse. In one practice known as doctor shopping, individuals seeking drugs repeatedly visit different physicians to obtain excessive prescriptions. Those who acquire prescription medications through this method may use them personally or sell them for profit. In addition, some individuals obtain these drugs illicitly purely for recreational purposes.

Another example is the so-called pill mill. Pill mills refer to networks of physicians and pharmacists who prescribe and dispense controlled substances to patients with drug dependencies. In this system, doctors at pain clinics write prescriptions for dependent patients, who then cash them in at local pharmacies. This arrangement generates substantial profits for both doctors and pharmacists, while simultaneously flooding the market with large quantities of prescription drugs.

A range of measures has been implemented at both the federal and state levels to address the opioid issues described above. One such measure is the Drug-Induced Homicide Act. Although this act predates the opioid crisis, its application has become increasingly common in recent years. This act was originally prompted by the death of Len Bias, once considered the top college basketball player in America, who died of a cocaine overdose in June 1986. In response to his death, a congressional committee initiated the Anti-Drug Abuse Act of 1986, which established penalties of a minimum of 20 years' imprisonment and a maximum of life for anyone who sold drugs that resulted in a user's death. Following the example set by the federal government, many states enacted similar laws. Today, 33 states have laws mirroring the federal provisions.

Another measure is the Prescription Drug Monitoring Program (PDMP). This program aims to prevent the acquisition of large quantities of drugs through practices such as doctor shopping and to promote appropriate prescribing, thereby reducing the risk of creating new cases of drug dependency. PDMPs are statewide electronic databases that collect designated data on medications dispensed within the state. The information recorded includes details on controlled substances prescribed by physicians and dispensed by pharmacies. Through this program, physicians can identify patients who obtain opioids from multiple medical providers and calculate the total daily opioid dosage per patient. This enhances patient safety while simultaneously curbing the flow of large quantities of opioids into the market.

While several measures have been implemented to address drug overdoses, problems and challenges have also been identified.

For example, consider the Drug-Induced Homicide Act. Critics have noted that, in practice, the act is often applied not to the drug dealers it was intended to target, but rather to family members, friends, or others close to the person who overdosed. The act is generally vague about who can be prosecuted under its provisions, typically listing only those who deliver or distribute controlled substances. In reality, it is often the loved one's present when a death from overdose occurs, and it is the loved one who face charges under the act.

Concerns have also been raised regarding Prescription Drug Monitoring Programs. The Centers for Medicare and Medicaid Services (CMS) noted the following: "Patients may feel like they cannot switch doctors because they will be seen as "doctor shopping" even if they are dissatisfied with the quality of the provider's care. Individuals with pain may change medications every few weeks or months even if the other medications are not as effective. Patients who are denied needed pain medications may turn to street drugs, which increase the risk of overdose."

The current fentanyl-related crisis appears to stem more from supply-side issues than from demand alone. Specifically, supply issues include the smuggling of controlled substances and the inappropriate overprescription of drugs by physicians, pharmacists, and others. Yet the conditions that allow and sustain this situation are arguably rooted in the broader social malaise and divisions felt by the American public. It seems clear that building a stable society, one in which people are not driven to rely on drugs, is a challenge that must be addressed by both federal and state governments in America.

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Reference Literature
*Excerpt from my article, The Opioid Abuse Crisis in the United States, Hakumon, No. 864 (2025), pp. 45 to 53.
*Centers for Medicare & Medicaid Services, Report to Congress: State Challenges and Best Practices Implementing PDMP Requirements Under Section 5042 of the SUPPORT Act, 2021, p. 38.