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 record-breaker. 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 multi-targeted strategy to restrict the importation of illicit fentanyl, and a broader, better-funded 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. There's no need to plant and protect acres and acres of poppies; fentanyl can be cooked up in a lab. 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 prescription-opioid 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.

From China, the pipeline flows mainly through the mail to users and dealers. Congress recently provided Customs and Border Protection with more chemical-detection equipment to screen packages. But given the volume of mail, scanning all of them isn't possible. The task would be easier if Congress passed pending legislation to require the U.S. Postal Service to obtain basic identifying information from senders — including the name and address of sender and a description of package contents — as private parcel services do.

Even so, a significant amount of the drug is likely to escape detection. Strenuous efforts will continue to be needed to crack down on the market within the United States. The Justice Department made progress recently by working with Dutch authorities to shut down two major sites on the dark web where deals were made, usually in virtual currencies.

Fentanyl is also sold on the ordinary internet, and Scott Gottlieb, commissioner of the Food and Drug Administration, is right to demand that internet companies work harder to remove the illegal listings. The FDA, for its part, could help limit supply by restricting off-label prescribing of legal fentanyl to patients who don't need, and may be harmed by, such a powerful painkiller.

The demand side must be confronted as well. More than 2 million Americans have opioid-use or heroin-use 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 opioid-based medications, which along with behavioral therapy have proved effective in overcoming addiction. Up to now, the Trump administration has ignored the need for medication-assisted therapy. Congress is considering bills that would expand its use somewhat — for instance, by getting Medicaid and Medicare to fund it more generously — but lawmakers aren't making this the priority it ought to be. Consider that, today, only 5 percent of U.S. doctors have had the training required to prescribe buprenorphine; far more doctors, as well as nurse practitioners and other health-care providers, should have the authority.

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

Instant Insights /

The opioid crisis is now a fentanyl crisis

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