The Iron Law of Prohibition
2022-11-18 · Guest: Dr. Jeffrey Singer and David Bier (Cato Institute) · 52:46
Fentanyl Crisis and US Border Policy
Bob Zadek, a San Francisco business attorney, explores the intersection of the fentanyl crisis and U.S. border policy with experts from the Cato Institute. Guests Dr. Jeffrey Singer and David Bier debunk the narrative that asylum seekers are responsible for fentanyl trafficking, explaining instead how the “Iron Law of Prohibition” and pandemic-era border restrictions incentivized the shift toward more potent, easily smuggled synthetic opioids.
Topics: Fentanyl crisis, Iron Law of Prohibition, border policy, immigration reform, harm reduction, drug prohibition, Cato Institute, DEA quotas.
Speakers:
- Bob Zadek – Host
- Dr. Jeffrey Singer – Senior Fellow at the Cato Institute and general surgeon
- David Bier – Associate Director of Immigration Studies at the Cato Institute
Introduction to the Fentanyl and Border Crisis [00:00]
Bob Zadek: Hello everyone, I’m Bob Zadek, host of the country’s longest-running libertarian broadcast, nationally streamed at 8:00 AM Pacific Time Sundays on the 860 AM app. My podcast contains more than a decade of historical issues. BobZadek.com offers resource material, book lists, other topical podcasts, and much more. We strive to offer in-depth content on social, political, and economic issues that really matter, and always with the ideal guests. Accessible and entertaining, our rule: ideas, not attitude.
In today’s show, I’ll seek the help of two experts to understand and perhaps solve two surprisingly related but intractable nationwide problems, which seem to just defy solution and are laden with misunderstanding: the flood of black market fentanyl on the one hand, and our open southern border—in fact, all of our borders—on the other hand. Is there a connection with the crisis at the border and with street fentanyl seeming to flood cities large and small in our country? Is there a connection? Is one the cause of the other? We have to find this out.
I’d like to welcome back to the show Dr. Jeffrey Singer. Jeff is a Senior Fellow at the Cato Institute and a practicing general surgeon. And also welcome to the show—yes, we have two guests today—David Bier. David is Associate Director of Immigration Studies at the Cato Institute. Gentlemen, welcome to the show this morning.
Dr. Jeffrey Singer: Thank you.
David Bier: Thanks for having me.
The Misconception of the “Open Border” [01:58]
Bob Zadek: Now, first, my first question to David. In the—we’re going to try to help our audience unpack these somewhat complex issues, and we’re going to try to undo a lot of the—and the word that we hear in the news all the time—much of the misinformation about the border in general, the open border, and specifically whether or not the open border contributes to or has any relationship to the fentanyl crisis. So first, David, you have written quite a bit on this. What in your view, as you observe what commentators are saying and what bloggers are writing, what is the claimed relationship between the crisis at the border, our inability to control our borders, and the flood—if there is a flood, and I guess there is—of black market fentanyl? What is the perception in the public as you see it about the connection between open borders, immigration, and fentanyl?
David Bier: Well, it’s pretty clearly stated that illegal immigrants are bringing fentanyl into the United States and selling it to Americans who are dying as a consequence of that. And it’s because we don’t have enough Border Patrol, it’s because we’re not enforcing our immigration laws strictly enough, that people are dying in the streets or in their homes or wherever as a result of this surge in production and trafficking in fentanyl.
Bob Zadek: So as a result of that perception or misperception—we will sort that out—do you perceive to be, are you concerned that there might be some animus directed towards open borders in general? That is to say, open borders or welcoming immigrants are in and of themselves, as a policy, contributing to the fentanyl crisis? Does that seem to be the perception that our thought leaders and bloggers, or many of them, are presenting? And is there any connection between the two in your studied opinion?
David Bier: Well, first of all, yes, I think members of the public are being told that asylum seekers—people who are seeking asylum in the United States because they have a fear of return to their home country—are contributing to the fentanyl crisis and that we need to end asylum in this country, immediately expel people back to either Mexico or to the country that they’re fleeing from. And we’ve seen this repeatedly used as a justification for policies that are not talking about, you know, whether we apprehend someone, whether we stop someone from crossing illegally; it’s about whether they can actually apply for a status in this country once they’re already in custody. And if they’re in custody, obviously they’re searched for fentanyl.
So at the base of it, there is the truth underlying this narrative is that most of the fentanyl coming into the U.S. now is coming from Mexico. The misperception is that it is primarily being trafficked into the United States by illegal immigrants crossing the border illegally. And that is entirely untrue. This is supported by every law enforcement agency in the federal government. They know that this is the case. They testified before Congress on this issue this year. Every single one: Customs and Border Protection, the Drug Enforcement Administration, the FBI—they all agree that the way that fentanyl and almost all other hard drugs enter the United States is through legal ports of entry where legal travelers are bringing fentanyl in their luggage, in cargo.
And it’s really easy because fentanyl is so potent that it’s easy to conceal, whether it’s in your package with your luggage or in a package as part of a larger shipment in legal cargo. It’s very easy to bring it in. And so that is why it makes more sense from the standpoint of a cartel or a drug trafficker to try to bring it in through these legal entry points than it is to try to sneak across the border with it on your back. Because the rate of apprehension, the rate of detection of people crossing the border illegally is actually much higher than people think it is. We have actually very good surveillance now. We have drones 24/7 in the skies, we have cameras all along the border. Of course, we don’t catch everyone, but we actually do have a pretty good idea about the total flow. And the rate of apprehension is greater than 50%, and the rate at which we’re intercepting fentanyl coming into this country is below 5%, and it has been for years. And so it doesn’t make sense from the standpoint of a drug trafficker to choose trying to sneak into the country with fentanyl compared to trying to sneak it in through a legal crossing as part of their luggage.
The Iron Law of Prohibition [07:29]
Bob Zadek: Now, Jeff, Dr. Singer, Jeff—fentanyl. There is so much misunderstanding about what fentanyl is, why it’s a crisis, and why are we reading about fentanyl all of a sudden so much in the news when there was a time fentanyl was never spoken anywhere? So help us understand, first of all, the big picture of why fentanyl became in the news at all. Was it filling an unfulfilled need? After all, we had lots of stimulants, lots of other illegal drugs before there was fentanyl. So why all of a sudden is fentanyl in the news to the exclusion, it seems, of other of the drugs we’re accustomed to reading about, such as heroin, marijuana to some degree, cocaine, and the like? How did fentanyl get to be in the news so much?
Dr. Jeffrey Singer: Well, I think I’d like to start off by saying, for those of your listeners who haven’t heard of this term, drug policy experts use a term “The Iron Law of Prohibition.” Basically, any economist understands this, but in shorthand: the harder the law enforcement, the harder the drug. So fentanyl has been around since the 1960s. It’s a synthetic opioid, which means nothing is derived from the opium plant; it’s made in a lab. It’s a very useful, effective opioid that we use in the operating room, we use for anesthetics, we use for people in intensive care. We use it usually in an injectable form, sometimes there’s a skin patch called Duragesic that we use, which is slowly absorbed through the skin over a few days. So it’s a very useful painkiller.
But it’s about maybe 50 times the potency of heroin, and heroin is about twice the potency of morphine. So it’s about 100 times the potency of morphine. Very potent. And therefore, a very small amount can get a lot of bang for the buck. That’s just recently the state of Tennessee Department of Health reported that. So that’s—and it’s being seen in Europe. So again, the Iron Law is continuously making drug dealers want to find and invent more potent forms of the drug. So if you really want to put the blame for the fentanyl crossing into our country and flooding the United States, you should really put the blame on prohibition.
David Bier: I just wanted to add one thing to that that really highlights this transition during the pandemic. Customs and Border Protection tracks their seizures of fentanyl and heroin. Basically, these are feeding into the same market. And at the beginning of the pandemic, about a third of their seizures were fentanyl. By the end of the restrictions on trade and travel with Mexico, it was 90% were being intercepted with fentanyl. So the restrictions at the border preventing trade and travel and free crossings really had a huge effect in shifting the black market away from heroin, which is less potent, to something that could supply the same market with 50 fewer trips. And that’s what makes sense from an economic perspective for the drug trafficking organizations. So we played right into their hands in creating this crisis.
The Shift from Heroin to Fentanyl [11:02]
Bob Zadek: Now, a question to either one of you, perhaps to Jeff first and then David. What was the externality that invited fentanyl into the marketplace? Because there was a period of time that when you heard about or read about the air-quotes “drug problem,” all the nouns were cocaine and heroin. You 20 years ago—my dates could be off—you weren’t hearing about fentanyl at all. Was there an external event, either a change in demand or was there governmental action or inaction that caused fentanyl to enter the market? After all, supply exists to satisfy a demand. Well, I think it’s fair to say there was a time that there was little or no demand for fentanyl, then there came a time that now there’s a great demand. So what happened? Is it only public taste or fashion, or is there something that caused fentanyl to become so much in demand? Because after all, it’s the demand that creates the supply coming in, as we all know.
Dr. Jeffrey Singer: Well, actually, Professor Dan Ciccarone at the UC San Francisco Medical School—he’s an addiction specialist, he’s been doing a lot of research for the NIH, a project called the “Heroin in Transition” project, where they’re actually interviewing intravenous heroin users on the street. And what he reported was that most IV drug users prefer heroin. It’s a completely different feeling you get. To quote him—he spoke at a Cato conference actually that I had—where he said, I’m paraphrasing now, that heroin is “warm and fuzzy,” whereas fentanyl is “bold and brash.”
Now, so most people seek heroin, but because, again, like I mentioned before, the Iron Law of Prohibition and then exacerbated by the border restrictions, it’s gradually become more economical for the cartels to supply the market with fentanyl. And now, over time, some heroin users have just kind of gotten used to using fentanyl instead. But most of them, if you gave them a choice, they’d prefer heroin. And they like to know if there’s fentanyl in their heroin because they want to adjust their dose accordingly.
Another interesting phenomenon—and this I learned recently from somebody in Arizona who runs a harm reduction organization—is that a lot of the fentanyl coming across the border here in Arizona, and probably in California, is in a pill form now. They’re making them as pills. They used to come more in powder or mixed in with things like mixed in with heroin so they could make the heroin more potent and thus smuggle it in smaller sizes. And a lot of the drug users find that the pills—it’s not very easy for them to make those pills into an injectable form, so they’ve gone to smoking them. And so now the new—in fact, this person I spoke to operates a needle exchange program, and she says we’re actually having to—we need fewer needles and more safe smoking equipment because the users tend to share like glass pipes that are cracked and they give each other cuts and spread infection. But on the other hand, from a doctor’s perspective, it’s actually safer to smoke it because usually you calibrate the dose you get to the desired effect. So when you take a couple of inhalations, and when you reach the desired level of effect, you stop. Whereas when you inject, it’s all in you, and if it’s more than you needed, it’s too late. So anyway, that’s just an interesting fact.
The History of Fentanyl Trafficking [15:08]
Bob Zadek: Now, David, in the history, in the relationship between the influx of fentanyl through, I’ll say, the southern border—I suppose that’s the more active place—if you were to chart out the influx, was it at one time heavier and enforcement made it less likely to occur because the likelihood of getting caught was greater? Or was there never—was the alleged flow of fentanyl through the southern border never very much, and the fear that it’s flowing through this open spigot, was that manufactured? Tell us, if you will, by quantity, a brief history of the relationship between the flow of fentanyl over time. Is there a graph?
David Bier: Sure. Yeah. About five or six years ago, most of the fentanyl that was coming into the country seemed to be coming in from China through the mail. China really cracked down on fentanyl production in its country, made it more difficult, so supply shifted directly to Mexico and really ramped up since then. And that, because it was easier to ship bulk from Mexico than it was to bring it in through the mail, it seemed like that had an effect on shifting the market. And so we saw every year from 2015 to this last year increasing rates of fentanyl being intercepted at the border. Again, 90% of it at the legal crossing points, maybe 10% or so coming across the border illegally, but both heading north every year.
But in 2020, there was a fundamental shift, and it happened almost immediately: April, May, June, July of that year, when they shut—basically, illegal immigration plummeted at the beginning of the pandemic. The South American, Central American countries had locked down their populations, there was very little movement, there were no jobs in the United States to go to. So illegal immigration was almost eliminated in April and May of 2020. But the flow of drugs didn’t stop. Obviously, people are still demanding drugs. And they had also at the same time restricted legal entry—only what they deemed “essential” travel was permitted from Mexico into the United States. And as a consequence, legal crossings plummeted as well. And so what the cartels did is they shifted overwhelmingly to using fentanyl and supplying fentanyl because they could supply the same market with 50 fewer trips. And that’s a very powerful economic incentive, and it happened at the same time that illegal immigration plummeted. And we saw deaths from 2019, when this policy of restricting immigration started, until 2021, deaths from fentanyl doubled, tragically, as a result of this shift in the market.
Why Fentanyl is Manufactured Abroad [18:32]
Bob Zadek: David, you’re an immigration expert, and so it’s appropriate for me to ask you this question. You, in your last comment of a moment ago, you mentioned that there came a time that immigration was restricted only to—and here comes the word—“essential” immigration. Now, I perked up when I heard that. I had an immediate PTSD flashback to the COVID epidemic and all of a sudden the only stores that could be open were those providing essential services. “Essential” became this word to hide behind in imposing irrational governmental restrictions and policies. And as you said it, David, I said to myself: what in the world qualifies as essential immigration? And I must ask you that because I can’t answer the question myself. Essential to the immigrant, or essential to the country, or essential to what exactly? And share with us, if you will, what could possibly be the standards by which essential immigration is measured?
David Bier: Yeah, I mean, at the end of the day, it really just came down to non-economic migration was basically prohibited. If you were coming to visit a family member or to wine and dine in San Diego or visit a—see a wedding or any of the normal activities that people would have engaged in before this was banned. And that included, of course, seeking asylum in the United States was deemed non-essential too, even though those people might die if they couldn’t cross the border. So they eliminated about 75% of all the entries at the Southwest border over that summer, and that’s when the fentanyl trafficking really picked up because it was much more difficult to bring in the same quantity of heroin as in the past. But ultimately, the market found a way to supply the same users as before; it was just a different substance and had pretty tragic consequences because no one was prepared for that shift in the marketplace.
Dr. Jeffrey Singer: I might want to add that now that the border—now that the restrictions have been lifted, it’s not as if the cartels are going to go back to, “Oh good, now we can start moving heroin across the border,” because they’ve learned that it’s much more economical for them to move fentanyl. And even though many users in the United States might prefer heroin, they’ve gotten accustomed to using fentanyl. If you gave them a choice, they may choose the heroin over the fentanyl, but fentanyl is, you know, at this point they’ve just kind of adjusted to it.
Bob Zadek: Now, perhaps a naive question. Is fentanyl—is so much of the fentanyl imported, brought across the border illegally, because if you try to manufacture it in the U.S., you’re likely to get caught? Or is it because it’s cheaper to manufacture outside the U.S.? Why is fentanyl not like moonshine, just grown in the hollows or manufactured in the hollows? Why imported versus manufactured in the U.S.?
Dr. Jeffrey Singer: Well, first of all, fentanyl, of course, licit fentanyl is manufactured in the U.S. There are pharmaceutical companies that make fentanyl for use in a hospital in the medical setting. And the Drug Enforcement Administration sets quotas on how much of every single category of painkiller, of controlled substance—whether it’s fentanyl or morphine or oxycodone—they actually are charged with having to decide for the next year just how much of every single one of these things the United States with a population of 330 million people will be needing that year. And they tell each company, “This is how much you can make that year,” which of course is an impossible thing to be able to figure out. But it’s obviously easier to make cheaply and out of the view of law enforcement outside of this country, and you can cobble together the ingredients you need to make it there.
Bob Zadek: So Jeff, is it the case—that sounds like a counterproductive policy, I’m sure it is—but the somewhat obvious question is, if that limitation were not imposed, if the government didn’t limit how much could be manufactured, creating an artificial shortage by governmental action, do you imagine that the amount of imported fentanyl across the border would diminish because—?
Dr. Jeffrey Singer: No. No, I was just saying that it is made in the United States, the licit fentanyl.
Bob Zadek: Then why import it?
Dr. Jeffrey Singer: For the same reason that methamphetamine, which is by the way a legal drug that’s made in the United States—it’s used to treat ADHD, the brand name is Desoxyn—but methamphetamine is made in meth labs, mostly in Mexico now. Originally, there were a lot of local domestic meth labs, but it’s easier to do it out of the purview, out of the sight of law enforcement when you go south of the border, or not necessarily even south of the border, elsewhere outside of the country, offshore, because otherwise law enforcement is always trying to, you know, surveil you. So it’s for that reason that it’s been driven out of this country.
Immigration as a Scapegoat for the Drug Crisis [24:37]
Bob Zadek: Now, David, is there any perceived relationship between our drug policy today—our immigration policy today—if you want to now, perhaps by calling it a policy is giving it far more credit than it’s due—perhaps I should say, is our immigration absence of policy, does it in any way contribute to the quantity of fentanyl? Is there any relationship between what we do at the border, what our policy is as a nation, and on the quantity of fentanyl that ends up on the streets? Or—I started my show by inquiring into the link, if any, between immigration and fentanyl. The public, or many of the public and a lot of policymakers, would have us believe there’s a relationship. And is there any relationship whatsoever, or is fentanyl merely being used as another argument to support restrictive drug policy, but in reality, it’s a false argument?
David Bier: Yes, it’s absolutely a false argument. We already mentioned examples of how border policy can make the problem worse—you know, restricting it to essential travel reduced the number of crossings, which made it more likely that fentanyl would be smuggled. But the reality is that 86% of drug traffickers who are convicted are U.S. citizens. And that statistic is, you know, people sort of pooh-pooh that and they say, “Well, the immigrants all get away with it.” And I just kind of laugh. There aren’t magical immigrants out there. If there was some way to get away with it, U.S. citizens would be, you know, crossing—you’d see U.S. citizens crossing the border illegally with fentanyl rather than trying to smuggle it through a port of entry if it was so easy to do that. And they’re not.
So it’s just, I think it’s, you know, it’s people who are so committed to making this tie and wanting to impose restrictive immigration policies that they’re willing to latch onto this argument to make it more serious. It doesn’t seem very serious to people if someone comes across the border and takes a job at a farm and picks, you know, fruit for the U.S. market. That doesn’t seem like a crisis that justifies radical action against immigration. And so people have to come up with this fentanyl tie-in in order to make people upset about people who are trying to help this country produce more things and bring down inflation and accomplish a lot for this nation. And yet they latch onto this unrelated phenomenon, largely driven by U.S. consumers, trafficked by U.S. citizens. And yeah, so it’s fear-mongering and it’s based on really an incomplete picture or an absence of knowledge about the facts of the situation.
Dr. Jeffrey Singer: I just want to add that what’s driving the fentanyl is the market. There’s a demand for drugs, and we have drug prohibition, so the demand is going to be met through the black market rather than through the legal market, period. Now, the only way I would say—and I don’t think you would disagree with me, David—the way that immigration ties in is that restrictive immigration sort of activates the Iron Law of Prohibition. So were it not for such restrictive immigration, perhaps fentanyl would not have emerged as a practical substitute for heroin. And so the tighter we make the immigration, the more we’re giving an incentive for the drug makers and dealers to try to come up with something even that they can even make in smaller quantities and get much more economic value for smuggling. So in that respect, our current restrictive immigration policy is stimulating the development of drugs like fentanyl or even stronger drugs.
David Bier: If we had actual open borders, we would not have a fentanyl crisis. It wouldn’t exist because fentanyl only exists—there was no natural demand for it initially—and it only exists as a method to avoid being intercepted at the border, at the U.S. border.
The “Fake” Arguments Against Immigration [29:35]
Bob Zadek: David, it seems to me that those who oppose—I’ll say open borders, but nobody really opposes open borders that broadly, but we mean perhaps a rational immigration policy, we’ll stop there for the minute—that those who oppose a more liberal immigration policy reach into their toolbox and they raise as many arguments as they can, none accurate. For example, we all have heard, “They take our jobs.” How absurd is that? That’s one argument. Another argument is, “They create more crime.” We know that’s not true. They create more crime because of cultural reasons. Another argument is, “They dilute American culture.” Ugh, I hate that argument more than others. So there’s this litany of all fake arguments. And fentanyl—is fentanyl just another one in a series of bad arguments used to justify a policy that cannot otherwise be justified on the merits? Or is there something—is there any truth at all to the fentanyl, or is it proper to lump it up with all the other phony arguments against immigration?
David Bier: Oh, it’s even more phony than the others because the restrictive immigration policy, as we mentioned, makes the problem worse. They’re actually, you know, making the situation that they claim they want to solve even worse by restricting immigration. So it’s even more absurd and inaccurate than those other ones that you listed. I mean, at least, you know, restricting immigration—I don’t even know what the good comparison would be—but this idea that fentanyl is a reason to restrict immigration makes no sense. It’s not logical.
And at the end of the day, if you want to clear the slate of Border Patrol so they can surveil every hour of every minute, let people come into the country legally. But they don’t want that policy. They don’t want people to check in and cross the border legally and come in and contribute to this country. The hardest question I have—I’m speaking personally now—about those who oppose a more liberal immigration policy is: is there one identifiable group, some unifying factor that describes why so many people appear to be opposed to a humane, rational, liberal immigration policy? To be sure, unions have an interest, appearing to be protecting American jobs. It’s fake, but they have it. So but that’s a clear defined economic interest. But the opposition—and I’m really asking you kind of a deep question, David—the opposition is broader than just union members. And is it simply a question of bootleggers and Baptists, a whole bunch of disparate groups find this unifying issue of open borders? Or is there—can you identify the source of all of the energy against immigration, or is there simply a whole bunch of separate sources?
David Bier: Well, I think there are a lot of separate sources, but I do think the unifying energy is in the chaotic images that cable news and social media spread. It looks like, you know, these people are criminals, they’re sneaking across the border, they’re evading Border Patrol and law enforcement. That doesn’t seem like a good thing. And it’s not a good thing, but the reaction should be we should be having a policy where people get vetted before they come, they fly on a visa, they get on a plane, they enter like anyone else, they go to a job legally where they’re not paid under the table and they can contribute like anyone else to this country, not to close the border and crack down even harder, which only creates even more chaos and more smuggling and more problems with law enforcement and government spending.
I mean, there are so many stories—I see stories every single day where I think, “That’s a real story. That’s like government is spending how much money on people who cross the border illegally?” But it’s only because they had to cross the border illegally that we’re spending this money. And so people get outraged when they see stories like we’re spending $10 billion to house illegal immigrants who just crossed the border, and it’s only because they crossed the border illegally that we’re spending this money. And so it’s really a self-reinforcing phenomenon. We start with the restrictive policy, it has chaotic elements, we waste a lot of money, people get mad about it, and then they want more restrictive policy rather than curing the problem by focusing on the underlying immigration issue.
Bob Zadek: The way I like to explain it, if I’m having a chat with somebody who says the platitude, “I oppose illegal immigration.” Well, that’s a tough one. Okay, “I oppose illegal immigration.” My retort is: do you oppose the illegal part or the immigrant part? And if you oppose the illegal part, in other words, once you change the law, then you’re there with a basket of donuts as they cross the border because you’re now welcoming them because they just became legal? Or is it the immigrant part that you oppose and you use in defense of your position the fact that it’s illegal? And that’s—and you have just expanded upon, I think, that issue. People take refuge in the fact they’re breaking the law. Well, they’re breaking the law because the law that tries to alter natural human behavior that doesn’t hurt anybody, those laws will always be broken because they’re contrary to the nature of humans. So I think that seems to be your answer, that there isn’t one cabal, not one unifying anti-immigrant party that simply is looking for a whole lot of arguments to justify that position. Everybody has a different reason, but perhaps because it’s so easy—“Hey, it’s illegal, and that’s why I oppose it”—that’s why they select that.
Harm Reduction and the Black Market [36:46]
Bob Zadek: Now, Jeff, you’ve studied the fentanyl crisis and more broadly the opioid crisis, and we’ve talked about it on my show many times. Do you say to yourself, or to your readers, or to those in the audience when you speak, do you point to immigration policy? Does it come up as one of the elements of your discussion of the fentanyl crisis, as if immigration policy is fixed, then what I’m here to speak to you about—speaking about yourself—declines in significance?
Dr. Jeffrey Singer: No, actually I don’t. To me, immigration is sort of besides the point. Although, like I said a little bit ago, restrictive immigration may help fuel the development of more potent forms of drugs to be smuggled. But it really—the drug overdose problem—that’s what I consider it, by the way, it’s a drug overdose problem, not a drug problem. And so maybe an HIV and hepatitis problem. So at bottom, it’s really a prohibition problem. Because all these things—it’s prohibition that makes all of this dangerous. You know, when we had alcohol prohibition, we had people dying from drinking denatured alcohol and tainted alcohol, and we had the development of big gangsters and gang wars. It’s the same thing all over again.
Alcohol use became—and alcohol still is a very dangerous drug. It’s actually pharmacologically speaking, it’s much more dangerous than opioids. Opioids don’t cause cirrhosis or heart damage or brain damage or cancer, but alcohol does. And yet when it was made legal, it’s made so much more safe because you can go into a store, you can see on the bottle what the ingredients are, there’s recourse if the manufacturer was lying and it was a higher strength of alcohol or it had impurities in it. So this whole overdose crisis is a direct result of drug prohibition. And all these other issues are basically exercises in deflection. They’re trying to deflect the blame. Like David pointed out, like we said in the Washington Post article a few weeks ago, you know, first they were blaming the doctors and the pharmaceutical companies for causing the overdose crisis. Then when it became fentanyl coming across the border, they’re blaming immigrants and illegal immigrants and a porous border. But that’s not going to fix it either. You could build an entire wall around this country; just look for something much more potent than fentanyl to emerge very quickly. It’s all about prohibition.
Bob Zadek: What I have learned from you, Jeff, and I’d like the audience to learn from you as I have, that part of the health problem, the death, the fentanyl-related deaths in this country, is in part because with legal fentanyl manufactured under the controls that our country imposes upon the manufacture and the labeling—very important component—and the labeling of fentanyl as to what it is and the potency, when you have legal fentanyl, the user will be able to make a more informed decision, including quantity. That’s not to say we want to make it per se—the issue is not to make it more convenient to be addicted or to abuse the product, but simply as you have said—the phrase I learned from you quite a while ago—harm reduction. That by opening up the marketplace to creating the demand we talked about earlier for fentanyl, which cannot be satisfied with the drug manufactured under the proper controls, you bring in unlabeled, poorly manufactured fentanyl, which means the user is uninformed and cannot control the quantity as much. So help us understand, explain for a bit as you have for me so many times, the relationship when the user, when the street is forced to use imported—it could be domestic, but as you have pointed out it’s not—imported black market fentanyl manufactured without controls, how that plays out in the abuse and death of fentanyl users.
Dr. Jeffrey Singer: Well, it’s because it’s on a black market that—that’s what makes it dangerous. So you can see what’s happened in a number of states now where they’ve legalized marijuana recreationally and there are actually stores you can go into. So just like nowadays in a liquor store, if you wanted to talk to the proprietor and ask him about, you know, “How much alcohol is in this particular product?” you could ask all sorts of questions. Well, if you go into a marijuana store, you could go up to somebody behind the counter and say—and I’ve seen this—where you could say, “Look, I’m a lightweight. I haven’t really used marijuana in 40 years, so consider me a beginner. What do you recommend I buy here?” And they’ll say, “Okay, well let me take you over to this case over here. This is very mild, lower THC concentration,” and they’ll actually give advice on how to use it. That’s what happens when things are legal.
And then people could openly share information with one another. They could make arrangements like we all do with, for example, if you’re going to be going to a party and you’re planning to drink heavily, so you know, you get a designated driver or you call an Uber to get home rather than driving. These are all forms of harm reduction. Basically, harm reduction is non-judgmental. The idea behind it is that regardless of whether or not I approve of your choices, I want to see your choices do less harm to you. So as a doctor, we do this all—I say to a lot of my colleagues, “You know, you may not realize this, but in an affluent developed country like the United States, the overwhelming majority of things that we do is practice harm reduction.”
So if you have a patient who, you know, has high blood pressure, mild diabetes, high cholesterol, you know they’re kind of heading down the highway towards a major heart attack or something like that, and you tell them, “You know, I could—I can get you—if I can get you on a diet and an exercise program, get your weight down, we can get your blood pressure under control, we can get your cholesterol down, you won’t even need anything for your diabetes.” And the patient, the person says, “Yeah, I know, but I can’t. I love to eat, I hate to exercise. I know I’ll stay on any diet you give me for a couple of weeks and then I’ll start to revert back to my habits.” So what do you do? So you prescribe a blood pressure pill and a drug to keep their blood sugar under better control like metformin and a statin drug to lower their cholesterol. Well, what you’re doing is you’re practicing harm reduction. You’re saying, “I’m not necessarily approving of your lifestyle choices, but I can’t control your lifestyle choices and I also have no right to. So let me do what I can to make it less likely that you’re going to harm yourself by continuing to live your life this way.” That’s all harm reduction is.
So for the people in this country, particularly you see on cable news, who are decrying the overdose crisis and they say 100,000 people died of overdoses this year, the biggest ever, another record—and it’s going to be a bigger one next year, it’s continuing to grow—well, if you don’t want people to die, then you should allow groups to give out things like clean syringes and needles. I mean, obviously you should legalize drugs, but if you’re not going to do that, at least allow people to give out clean needles and syringes, to allow doctors to prescribe methadone directly to patients instead of them having to go to these prison-like clinics. And there are a whole host of harm reduction measures that are prohibited by laws in this country because the lawmakers say, “I don’t want to be seen as enabling or endorsing your choice.” But really, that’s not what you should be concerned about. You should be concerned that these people are dying. And so that’s where the efforts should be placed.
Attainable Policy Solutions [45:34]
Bob Zadek: Now, David, we have only a few minutes left until it’s time for me to ask the most provocative question of the century, which would take you about a semester to answer. That’s my usual trap that I do with guests. I’ll try not to do that. But David, the immigration policy in this country has, looking at the past, unsolvable. Congress is unable to act, deferring to the President using alleged executive powers. Now, at Cato, you publish so much valuable information about what’s wrong with immigration policy. Now, what is the low-hanging fruit, the somewhat attainable changes that you can see so that our listeners, if they or when they understand the contribution to the fentanyl problem and to a lot of the country’s ills is a—it’s almost a hyphenated word, “failed immigration policy”—what are the some of the easy solutions that are attainable that you would recommend that we focus on?
David Bier: Ha! If I could tell you what is attainable, then I would be a very, very—
Bob Zadek: Then you would be a guest on my show!
David Bier: But let me—I mean, look, there’s problems all along the immigration spectrum. Everything from the physician shortage in the United States is severe. Everyone knows it, everyone agrees on it. This should be something that Congress should be able to take care of. It ties into the healthcare crisis, mental health crisis in the United States, and we do nothing about it year after year after year. We have the same number of green cards for employer-sponsored immigrants that we had in 1990, over 30 years ago. We’re using the same cap on employer-sponsored immigrants, which includes everything from geniuses to physicians all along the spectrum. And there’s no way to get into this country and contribute in a meaningful way. The United States has half as many physicians per capita as most developed countries, and it’s a consequence of our outdated immigration laws, also our licensure laws at the state level. Jeff can speak more to that.
So I think that, the healthcare workforce issues on immigration should be something that every American cares about. It should be easy for Congress to address. If you look at it, you know, it’s not just physicians, it’s also nurses that we have a need for. We have no work visa that enables nurses to enter right away. They’re not eligible for the H-1B visa. They’re only eligible if they get a green card right away, which is a great disincentive for employers to sponsor people because that process is so costly and the nurse can leave immediately after they’ve been hired. Some hospitals they still do it, they’ll go through that process even though they know the nurse could leave them right away. But it’s a big disincentive to getting people into the country when you have that kind of process. So healthcare, physicians all the way down to home health aides, are in desperate need. We’re an aging population, we need to get that done.
At the border, unfortunately, we’re not anywhere close to a consensus about how to handle that. But we need to work out a deal at least with Mexico on some guest workers who can come in and work in some of these open positions in the United States without having to cross the border illegally. The situation is untenable. We can’t keep filling jobs in this country by letting people cross the Rio Grande and have a thousand die every year.
Bob Zadek: And what you’ve really just proposed as a starting point, what I found in your solution—doctors, nurses, guest workers—is there are no victims of that policy. There’s no group who will feel threatened by that type of a proposal. So to hope for widespread immigration reform, it’s just—it’s unattainable. But taking the shots one at a time and just going for, as I said, the low-hanging fruit, it’s so easy to obtain. And once you do, we get used to, incrementally, a more enlightened immigration policy. And I’ll close by pointing out to our listeners that I use the phrase, we all use the phrase, “immigration reform.” Rhetorical question: did you ever notice that whenever we use the word “reform” in public policy, what we are reforming is another policy? It’s a bad policy that creates the reform business. So how about not messing up to begin with, and then there’s less to reform? That’s for another show and another day.
Thank you so much, David Bier and Dr. Jeff Singer, for sharing with us their thoughts on fentanyl and its relationship, if any, to the open borders—if they are in fact open, which they probably are not, they’re just chaotic. And most of equal importance, thanks so much to your wonderful colleagues at the Cato Institute for all of the wonderful work they do. Every time I read a blog or open up a publication from Cato, I can’t help but feel smarter and more informed. So thank you so much, my friends, and thank you to Cato, and thank you to my listeners for giving us an hour of your valuable time. I hope you have found it worthwhile. Thanks so much.