Recently I worked in another Maine city and was astonished at the number of patients I encountered who were using heroin.  I had never seen anything like it, during a lifetime practicing medicine. In New Hampshire, it was said, deaths from heroin now exceed deaths from car accidents.  Nationwide, CDC noted, “Between 2002 and 2013, the rate of heroin-related overdose deaths nearly quadrupled, and more than 8,200 people died in 2013.”  Massachusetts (population under 7 million) had 1,000 deaths related to (all) opioids in 2014, “the highest ever recorded.“

I’ve heard stories on NPR about insufficient state funding of heroin treatment facilities. I’ve heard about plans to make Narcan injections available to iv drug users, for overdoses. Another popular angle I’ve seen repeated multiple times (and one currently pushed by the US Drug Enforcement Agency) claims prescription narcotics became harder to get, so users switched to heroin, instead.

However, the DOJ-DEA 2014 National Drug Threat Assessment Summary notes that cocaine availability “remains stable at historically low levels throughout most domestic markets along the East Coast.”  So users are switching to heroin, but not switching to cocaine from prescription narcotics. Hmmm. Might this be because we have no large military-CIA presence currently in cocaine-trafficking areas, as we did during the 1980s Contra war in Nicaragua, when cocaine use was at high levels? (Coca leaves are only grown in Latin America.) According to a 2010 UN document, “Based on seizure figures, it appears that cocaine markets grew most dramatically during the 1980s, when the amounts seized increased by more than 40% per year”.  (See this 1987 Senate hearing and this for evidence of CIA and State Dept. connivance with cocaine trafficking by the Contras.)

You can frame stories about the current heroin problem in many ways.  But the real heroin story isn’t being discussed–which is that since the US military entered Afghanistan in 2001, its opium production doubled, per the UN Afghanistan Opium Survey, 2014 , p.34.  The area under opium cultivation in Afghanistan tripled. And the resulting heroin appears to more easily make its way deep into our rural, as well as urban communities. The graph below is from the 2014 UN Opium Survey:

The world supply of opium increased 5-fold between 1980 and 2010, according to the UN.“Afghanistan account[s] for around 90% of global illicit opium production in recent years. By itself, Afghanistan provides 85% of the estimated global heroin and morphine supply, a near monopoly.”(see pp 37-38).

The narcotics trade poisons the Afghan financial sector and undermines the Afghan state’s legitimacy by stoking corruption, sustaining criminal networks, and providing significant financial support to the Taliban and other insurgent groups,” John F. Sopko, the Special Inspector General for Afghanistan reconstruction, said in an October 2014 letter to the heads of the Departments of Defense, State and Justice, which have all played major roles in the failed drug intervention effort. “Despite spending over $7 billion to combat opium poppy cultivation and to develop the Afghan government’s counter-narcotics capacity, opium poppy cultivation levels in Afghanistan hit an all-time high in 2013.

Despite the (now) US $8.4 billion spent to defeat this trade, it just keeps growing.  The costs of US reconstruction efforts in Afghanistan total “$110 billion, after adjusting for inflation, [which] exceeds the value of the entire Marshall Plan effort to rebuild Western Europe after World War II” according to the Special Inspector General for Afghanistan Reconstruction, speaking in May 2015.

The Special Inspector General noted elsewhere that, “US reconstruction projects, particularly those devoted to “improved irrigation, roads, and agricultural assistance” were probably leading to the explosion in opium cultivation.“

Only 1.2% of the acreage used for Afghan opium production (est. 224,000 hectares) was eradicated in 2014, according to the UN. Also according to the UN, Burma is the world’s second largest producer of opium, currently growing only about 10% as much as Afghanistan. But Mexico has been increasing production.

According to the UN World Drug Report, in the 1990’s Afghanistan supplied opium that was converted into half the world’s heroin production.  By 2010, it supplied 90% of the total.

But the DEA, White House and other official US sources claim that US heroin derives almost entirely (96%) from Latin American opium (based on seizures of shipments); the DEA in 2014 claimed that Latin America was the source for the vast majority of US heroin, with southwest Asia (i.e., Afghanistan) accounting for only 4% of US heroin in 2012.

This is highly unlikely.  In 2008, the UN estimated that the US and Canada accounted for 13% of global heroin use.  With about 95% of global heroin derived from Afghanistan, Burma, Thailand and Laos, Latin America (mainly Mexico with a small amount from Colombia) does not produce enough to supply the majority of US heroin, let alone 96%. In fact, the White House Office of National Drug Control Policy undercuts this claim when it says Mexico had 10,500 hectares under poppy cultivation in 2012, while Afghanistan alone had 154,000 hectares in 2012 and 224,000 hectares in 2014, per UN estimates.

This DEA claim, based on heroin interdiction, suggests a different explanation.  Perhaps heroin shipments from Afghanistan are at lower risk of being seized than heroin coming from Latin America. Might some be entering through government channels, when so much materiel and so many personnel (soldiers, aid workers, diplomats and contractors) fly directly between the US and Afghanistan?

Putting aside the issue of the provenance of the US heroin supply for the moment, surely we can look at heroin as we would any other global commodity.

Congruent with the US occupation of Afghanistan, Afghanistan expanded its opium production, and the global supply of heroin increased dramatically. The price dropped as a result. New buyers entered the market. And the US now has several hundred thousand new addicts.  Russia and Europe have even more. The resulting social problems are hugely tragic and hugely costly for millions of families, and for our societies as a whole.

If we start being honest about why there is a major heroin epidemic, maybe we can get serious about solving the problem with meaningful eradication and interdiction. Aerial spraying of crops with herbicides or similar methods has been prohibited in Afghanistan, but it works. In 2014, Britain’s former Ambassador to Afghanistan (2010-2012) called for legalization and regulation of illicit drugs as one means of attacking the problem.

Looking beyond the Mexican border for heroin, and inspecting all flights from southwest Asia, including military and CIA flights, could have a large impact on supply as well.

Serious measures are needed.  Total world production of opiates always gets consumed: historically, the market for opiates has been extremely elastic.  Land under poppy cultivation (in Afghanistan, Southeast Asia’s Golden Triangle and Mexico) continues to increase. Without meaningful efforts to reduce opium production and entry of narcotics into the US, the epidemic of heroin addiction may become a considerably bigger problem than it is today.

UPDATE:  From the Sept 7 Wall Street Journal, we learn that a US “friendly fire” airstrike in southern Afghanistan on Sept 6 “hit a 30 member elite counternarcotics police unit as they were on a mission…”

At least 11 died in “one of the deadliest friendly fire incidents in the country in recent years.” Here is the Reuters story. The US denied the strike in Helmand province, but admitted to airstrikes in the adjacent province of Kandahar. According to the Guardian, “The US is the only member of the NATO coalition known to have carried out bombing raids in Afghanistan this year.” The AP/WaPo on 9/8/15 reported that, “Brigadier General Shoffner [Deputy Chief of Staff for Communications in Afghanistan] said ‘based on information we received [on 9/8], we feel it is prudent to investigate the airstrike our forces conducted in Kandahar.’”

The airstrike killed approximately as many people as died in counternarcotics efforts in all Afghanistan throughout 2014.

I will have more to say about the subject of heroin in a later post.

Meryl Nass, M.D.  is  a board-certified internist and a biological warfare epidemiologist and expert in anthrax. Nass publishes Anthrax Vaccine.

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