The opioid crisis has turned into a fentanyl crisis

America’s opioid crisis has shifted. As Congress and the White House have dawdled, the overdose death toll has continued its steady climb — reaching more than 49,000 in 2017, an increase of nearly 7,000 over the previous year, itself a recordbreaker. But the primary agent of death is no longer ordinary prescription painkillers. It’s illicit fentanyl, often mixed with heroin or some other street drug.

This change calls for an equally drastic shift in the effort to prevent opioid deaths. Tighter controls on prescriptions for oxycodone and hydrocodone are no longer enough to limit supply. The U.S. needs a comprehensive and multitargeted strategy to restrict the importation of illicit fentanyl, and a broader, betterfunded push to reduce its demand.

Since 2011, fatal overdoses from drugstore opioids alone have remained relatively stable, but those involving fentanyl have shot through the roof. The far more lethal drug played a part in 60 percent of opioid deaths in 2017, according to the National Center on Health Statistics, up from 11 percent five years ago.

Fentanyl, created in 1960 as a treatment for cancer pain, has become popular on the black market in part because it’s synthetic. And because it is so potent — a smattering of grains packs a deadly dose — it can be mailed around the world in tiny, concealable packages. Drug labs in China fulfill online orders from American users, or from traffickers in the U.S. and Mexico who add the fentanyl to heroin and other drugs to boost their effect, or press it into phony prescriptionopioid pills.

A coordinated response to the crisis needs to start with China, which, according to U.S. law enforcement, is the source of almost all illicit fentanyl. Poorly monitored and regulated chemical laboratories there sell fentanyl or its precursors to U.S. users and dealers, or to Mexican drug suppliers who in turn market it in the U.S.

The Obama administration had begun to enlist the Chinese government’s help in policing producers, including by persuading China to add many analogues of fentanyl to its list of controlled chemical substances. President Donald Trump has preferred to accuse and threaten, which doesn’t encourage cooperation. What’s needed is a steady and purposeful diplomatic push, along with expert support for fortifying China’s capacity to inspect and regulate its thousands of drug labs.

The demand side must be confronted as well. More than 2 million Americans have opioiduse or heroinuse disorders, and few can be expected to quit without help. They need to be brought into treatment at every opportunity, most obviously when they enter hospitals, emergency rooms or prisons. And this treatment should include methadone, buprenorphine and other opioidbased medications, which along with behavioral therapy have proved effective in overcoming addiction.

Fentanyl and other opioids are killing more than 130 people a day. The crisis demands a thorough, wellcoordinated national response. What the White House and Congress have come up with so far falls short.