During the Internazionale Festival, which took place from the 29th September to the 1st October 2023 in Ferrara, we met Keegan Hamilton, a North American journalist. He covers criminal justice, drugs and organized crime. Keegan currently is a criminal justice editor at Los Angeles Times, previously at Vice news, and his articles have been published by The Atlantic, The Village Voice and BuzzFeed News. He also is the host and co-creator of the award-winning podcast series Painkiller: America’s fentanyl crisis (2020).
The crisis caused by opioid overdoses is one of the most serious crises facing the United States at this time in history. Fentanyl is a very potent synthetic opioid: fifty times stronger than heroin and one hundred times stronger than morphine. It originated as a medicine in the 1960s for the treatment of oncological diseases and in surgeries. For the past seven years, however, it has been smuggled and sold illegally on the streets in the United States.
In 2021, 106,699 deaths were caused by opioid overdose in the United States. In two thirds of the cases, fentanyl was the cause.
Why and when did you become interested in the opioid crisis in the United States?
The opioid crisis in the United States has been going on for almost all of my adult life, and I am 38 right now. Ever since the early 2000s, when I was in high school, we first started to see a rise in overdose deaths and addiction. First from pharmaceutical pills, then heroin and most recently fentanyl. And so to me, as an American, it’s just everywhere. You can’t escape it.
You always know someone who is struggling with addiction or some cases have died from an overdose. And part of the purpose of the podcast was to understand hy fentanyl? And how did it come to this? And then the secondary, and I think more important and deeper question is why are people using drugs in the first place? What drives someone to use fentanyl? And so that’s really what we set out to investigate this seriously.
What features made fentanyl so popular?
It is interesting that it was not initially driven by a demand from [drug]users – there was a demand for opioid drugs: pills and then heroin. After, it was a supply-created problem where the drug dealers, in this case cartels from Mexico, looked at this problem and said: «We are supplying this market, but we are using something that is a finite resource, which is poppy plants».
You need a huge amount of poppy plants to make a kilo of heroin. Whereas with fentanyl you just need some chemicals and someone with the knowledge to make the drug. From a financial perspective, that is a lot more lucrative because you do not have to pay a farmer, you do not have to pay to process the drug, You can just have one person working twenty four hours and seven days a week making this stuff. This way, the money that you can bring in from that production is almost pure profit.
It is more money – that is why. And now that it has been introduced and people are used to it and addicted to it, there is demand. But it did not start because people said: «I want fentanyl». They were given fentanyl and then they became addicted to it. And now it is the drug that is everywhere.
In the podcast you talk about opioid refugees, who are they?
So, as the problem of overdoses and addiction has grown in the United States, there has been a backlash against prescribing opioid drugs for pain, on the theory that these were causing so many people to become addicted, and there is truth behind. But as the United States government, the law enforcement, has tried to crack down on the opioids and this has had the unintended consequence of making it really hard for people who might have legitimate medical needs for fentanyl to get the drug. It is so stigmatized and associated with addiction that someone in law enforcement will tell them they have no reason to take it, as if they knew what works for them.
Opioid refugees are people whose doctors have been either shut down, arrested by the government, or have just stopped prescribing [opioids] because they are afraid of getting arrested. Also, opioid refugees are for example those who had a prescription from a doctor but lost it and are now trying to find another doctor who will give them the prescription for what they were taking before.
How much does the fact that in the United States there is not a public health system affect the opioid crisis?
I think it is completely intertwined. The healthcare system in the United States and the drug addiction problem are inseparable. One of the things that we set out to investigate with the podcast is “Why do people use drugs like fentanyl?”. And we kept coming back to either untreated, physical pain, some sort of injury, a back problem, or untreated mental health problems: if you are traumatized by some event in your life and you are self-medicating not to feel that existential pain.
If the United States had a healthcare system that functioned better and was more accessible and not so expensive, I think a lot of those underlying causes that drive people to use a drug like fentanyl could be addressed.
What steps have United States Institutions taken to try to curb the crisis? And are they succeeding?
One of them we talked about, which is going after doctors that prescribe opioids and trying to make the supply of prescription pills go down. The other supply-side approaches that we see are trying to arrest cartel leaders like El Chapo and his son, and pressuring foreign governments to do something about the source of supply. So that Mexico, China and the US have used a lot of diplomatic pressure to try to make those countries crack down on the drug production there that does not do anything for the demand of the drug in the United States.
There have been a lot of conversations around treating drug users more humanely and making it easier for people who have a drug addiction to access rehab for addiction treatment. Still, so many of these rehabilitation programmes in the United States do not embrace substitution therapies that can help people wean themselves off like methadone, buprenorphine or drugs that are another less addictive opioid. So there is still a big emphasis on abstinence and cold turkey [attitude], having people to stop using drugs and that doesn’t work – people relapse and they die, given that when they stop using opioids for a while they lose their tolerance, and when they try to use the amount that they were using before they overdose.
Overall, I think the US needs to have a greater emphasis on mental health treatment, on providing substitution therapies like methadone and buprenorphine, and also treating people overall like more holistic medical and mental health services. It is a lot easier to fixate on the simple solution, which is if we just prevent these drugs from getting into our country, then the problem will go away. That is kind of a fantasy.
I just came from an event where people were asking: “Why do we not have this in Europe?” Part of the reason is that European healthcare systems are a lot better and more accessible and so some of these underlying causes that are driving people to use opioids just do not exist here. In this regard, Europe has been really lucky to not have fentanyl for some of the reasons we said, and given that the healthcare system is better here. However, I think, as I said earlier, in the US it was supplied. It was not that people wanted fentanyl, but it appeared and then it became very addictive. Right now in Europe there are heroin users, but the heroin is coming from Afghanistan and there is still a large cheap supply of poppy coming from there. Now, the Talibans in power are cracking down on poppy production in their country because of pressure exerted by the United States. If there no longer is a stable supply of poppy and heroin from Afghanistan that is where I think the risk of a surge of fentanyl use comes into sort of fill the void that the lack of heroin leaves behind. For instance, Estonia had a fentanyl problem for a number of years, but it was short-lived. So it can happen, there is no reason that fentanyl can not come here, except for the fact that people are accustomed to heroin, which is still cheap and available.
Listening to your podcast or also watching the Netflix series Oxycontin it is not so easy to practice the absence of judgment. Whether we consider people to be victims or perpetrators. It is easy to simplify difficult on the other end, to fail to enter into the complexity of the life of these people and into the complexity of the problem. What is the same for you? How did you manage to tell the complexity?
That is a great question. I think it is really easy to dehumanize drug users, especially when it goes hand in hand with homelessness and drug use in public. If you walk around in a major American city I live in, San Francisco, it is hard to escape it. You see people who are using drugs and the immediate judgment is to think of them as less than human. That is the opposite of what we tried to achieve in this podcast, as we aimed to talk to people who are using drugs and to understand their motives – We kept coming back to the same things, which is what we have been talking about: untreated physical and mental pain. Once you have that conversation and you speak to them one-on-one, and understand that they are just like us, that your life could have been a little bit different. I could have had a traumatic injury that made me take painkillers and then get addicted to them. Luckily, that did not happen.
