Demand reduction only works if people know what they are buying
The basic problem with demand reduction strategies is that lots of people who overdose on fentanyl don't know that they are taking it. As the CDC explains:
Powdered fentanyl looks just like many other drugs. It is commonly
mixed with drugs like heroin, cocaine, and methamphetamine and made
into pills that are made to resemble other prescription opioids.
Fentanyl-laced drugs are extremely dangerous, and many people may be
unaware that their drugs are laced with fentanyl.
The incentive to use fentanyl is the black market for drugs is driven by the fact that fentanyl delivers more doses per kilogram than almost any other drug on the market, making it more attractive to smuggle, because the difficulty involved in smuggling drugs is basically proportionate to the mass and volume of drugs smuggled. From the same CDC link:
Fentanyl is a synthetic opioid that is up to 50 times stronger than
heroin and 100 times stronger than morphine. It is a major contributor
to fatal and nonfatal overdoses in the U.S.
There are two types of fentanyl: pharmaceutical fentanyl and illegally
made fentanyl. Both are considered synthetic opioids. Pharmaceutical
fentanyl is prescribed by doctors to treat severe pain, especially
after surgery and for advanced-stage cancer.
However, most recent cases of fentanyl-related overdose are linked to
illegally made fentanyl, which is distributed through illegal drug
markets for its heroin-like effect. It is often added to other drugs
because of its extreme potency, which makes drugs cheaper, more
powerful, more addictive, and more dangerous.
Put another way, fentanyl use is surging because the wholesale price per dose is much lower, because the cost of smuggling drugs dwarfs the cost of synthesizing it, and fentanyl is much cheaper to smuggle.
So, someone may think that they are buying heroin, but actually be buying sugar or chalk cut with a much smaller volume of fentanyl, providing a comparable dose to that amount of heroin.
But without medical laboratory class equipment and technician skills, it is much easier to err by overdosing or underdosing something cut with fentanyl than it is with a less potent drug, because a seemingly trivial fraction of a gram can be the difference between the intended dose and a fatal overdose.
Fentanyl is even routinely cut into non-opiate illegal drugs, because it gives the user a potent effect and is addictive.
But, demand based efforts only work to prevent people from buying fentanyl when they know that they are buying it. For example, PR efforts like the "One Pill Kills" campaign in Texas haven't had any appreciable positive impact.
Indeed, anecdotally, it appears that lots of people are skeptical of using fentanyl in medically prescribed settings because of the bad press that the drug has gotten from the abuse of illegal fentanyl. I am personally aware of several people who have either declined fentanyl treatment, or only agreed to it after extensive discussions with health care providers, in cases where it was appropriate, who prior to widespread publicity related to fentanyl wouldn't have given it a second thought. So, if anything, demand reduction approaches are currently backfiring.
Pharmaceutical fentanyl abuse
Some people do know that they are taking fentanyl and prefer it, but this is the exception rather than the rule.
But people who are getting fentanyl when they are intending to get fentanyl are often getting product diverted from legitimate hospital supplies where the dosage is trustworthy and the drugs are pure. This isn't the population that is experiencing the lion's share of the harmful consequences of taking fentanyl, however. The people who are diverting pharmaceutical fentanyl are not really significantly worse off that people who illegally take less potent opiates.
Other harm reduction measures
There are generalized harm reduction measures, like supervised injection/drug use sites, and widespread distribution of narcan (an opiate antidote) along with immunity from civil and criminal liability for those who help respond to overdose situations. But many jurisdictions are uncomfortable with affording any legitimacy to conduct that they've made a serious crime otherwise.
Distributing test strips for fentanyl so people know what they are doing, can help, but this approach hasn't really been rolled out on a big scale yet.
A lot of the larger opiate addiction problem in the U.S. comes from a failure to make drug based (mostly methadone and buprenorphine based) treatment options widely available from low cost, easily access providers. Requiring primary care doctors to make this kind of opiate addiction treatment widely available is, for example, the main reason that the opiate addiction problem was curtailed in France, starting in 1996, while it continued to surge in the U.S. where such treatment is frowned up and hard to get. Cold turkey is the norm in the U.S. and causes lots of jailhouse withdrawal deaths. As discussed below, however, in December of 2022 the U.S. passed legislation intended to shift U.S. policy on opioid addiction treatment in the French direction.
In France, overdose deaths are now concentrated in methadone users, because the addiction program has been controlled with general practice drug based treatments, so widely availability of narcan there is the current focus.
Serious efforts to reform prescriptions of opiate pain killers to prevent people from becoming addicted have had only modest success so far
Lots of changes in how medical providers prescribe opiates were made to address the opiate addiction problems in the twenty teens. As the Kaiser Family Foundation explains at the link:
The opioid overdose epidemic, characterized by the rapid rise in
opioid-involved overdoses and overdose-related deaths, began in the
late 1990s, driven by increased prescribing of opioids to treat pain.
In subsequent years, the epidemic evolved, and is now largely driven
by synthetic opioid-involved deaths, including illicitly manufactured
fentanyl. Medicaid enrollees have been particularly impacted by the
opioid epidemic, with higher rates of substance use disorder (SUD) and
prescribed opioids among Medicaid enrollees compared to people with
other types of insurance. To combat the opioid overdose epidemic,
policymakers have enacted legislation to reduce opioid prescriptions
for pain and increase access to treatment for opioid use disorder
(OUD), and the Consolidated Appropriations Act, passed in December
2022, vastly increased the number of providers authorized to prescribe
controlled substance medication treatment to treat OUD.
This analysis builds on previous KFF work by using Medicaid claims
data, administrative data on Medicaid enrollees’ health care
utilization, for 2016-2019 to explore how prescriptions for opioids
used to treat pain and those used to treat OUD or rapidly reverse
overdose changed across states and enrollee demographic groups over
time leading up to the COVID-19 pandemic. A full description of the
data and methods can be found in the Methods section. Key findings
include the following:
Opioid prescriptions declined overall from 2016 to 2019, driven by a 44% decline in the number of prescriptions for opioids used to treat
pain. At the same time, prescriptions for medications used to treat
OUD or rapidly reverse opioid overdose doubled, driven by an increase
in buprenorphine prescriptions.
The share of enrollees receiving at least one opioid prescription for pain declined from 11.3% in 2016 to 7.2% in 2019, which drove the
overall declines in utilization of opioids to treat pain. The
magnitude of declines varied by state, eligibility group, and
race/ethnicity.
The share of enrollees receiving at least one medication used to treat OUD or reverse opioid overdose doubled from 2016 to 2019.
Compared to Black and Hispanic enrollees, White enrollees were more
likely to receive at least one treatment prescription and saw the
largest increase their share over the period, suggesting racial
disparities in access to prescription medication to treat OUD or
reverse overdose.
But the problem of opiate overdose deaths has continued to grow, and illegally manufactured fentanyl products have continued to be a severe and growing problem. See the chart below (from here):
Why are European comparisons relevant?
Examples like France, Switzerland and Portugal that have taken a less punitive approach to drug addiction are relevant, contrary to the OP, because this less punitive approach has reduced the intense pressure to make smuggled drugs more potent per volume/mass that exists in the U.S. and Canada, reducing the market pressure to introduce fentanyl into the black market for psychoactive drugs.
