习、拜握手与“芬太尼”那张牌 （Xi, Biden Handshake and the Fentanyl Card）
Taking advantage of the APEC opportunity, President Xi Jinping sailed across the ocean, bringing his "Red Flag" armored vehicle to San Francisco to shake hands with Biden for the second time. The last time they shook hands, Biden was the Vice President. Approaching 80 and still holding a job with promotions, he is indeed a “miracle” in American history.
The bilateral talks lasted for more than four hours, covering many major issues such as restoring high-level military communication, the Taiwan issue, the Ukraine issue, the Hamas issue, and more. To be honest, I'm not very concerned about these matters; they will unfold as they will, and a handshake won't necessarily bring about any changes.
However, in their exchange, a "small matter" was involved: the fentanyl issue. In fact, this problem is a significant one for the United States. It is currently the leading cause of death among middle-aged and young Americans and is escalating. I hope that after this meeting, according to President Xi's commitment, things can improve in the coming years.
什么是芬太尼 What is Fentanyl?
Fentanyl is a potent opioid analgesic, about 100 times more powerful than morphine. Developed in the 1960s, it quickly became the most widely used synthetic opioid in medicine. [Note: There is a distinction between opioids and opium. Opium is a mixture of alkaloids extracted from poppy fruit and has analgesic and addictive properties. Opioids encompass a broader category of synthetic or semi-synthetic compounds, including fentanyl, and are generally more potent than opium.]
Some may wonder, with pain relievers like ibuprofen, acetaminophen, lidocaine, etc., why use opioid analgesics? The main reason is that while drugs like ibuprofen are effective for headaches, fever, or general localized pain, they are not sufficient for severe pain resulting from injuries, surgeries, late-stage cancer, etc. For such intense pain, opioid analgesics like morphine, meperidine (Demerol), oxycodone (OxyContin), and fentanyl are needed. In short, fentanyl is used clinically as a powerful analgesic.
Opioid analgesics act on three receptors in the brain's nerve cells (neurons): μ-type, δ-type, and κ-type receptors. Unfortunately, these receptors, when activated, not only produce strong analgesia but also have a close relationship with the development of dependence. Therefore, these drugs are controlled substances. Due to the significant drawback of addiction, developing non-addictive analgesics has become an important topic in drug research. The National Institutes of Health (NIH) in the United States started a PSPP program a few years ago, attempting to make breakthroughs, but it seems very challenging. Some scholars even believe that separating opioid receptors associated with addiction from the analgesic effect is not feasible.
芬太尼为什么杀人 Why is Fentanyl Deadly?
While drug addicts use various illicit substances, most deaths are caused by opioid use. Even in medical settings as pain relievers, improper use can lead to overdose, with severe cases resulting in death. Other types of drugs, such as cocaine, methamphetamine, ketamine, etc., are less likely to cause death. Why is that?
原来，阿片受体，特别是k受体在下丘脑呼吸中枢广泛分布。如果过服，就会导致呼吸抑制。特别重要的是，阿片受体都具有很明显的“耐受”的特性。当反复服用阿片类药物时，受体的敏感性会下降。这时候，同样剂量的阿片类药物就不那么“有劲”，不能产生相同的镇痛效果或愉悦感了。 这就叫做药物耐受性（tolerance）。 阿片类药物的耐受性驱使使用者增加剂量，这样他们才能保持镇痛效果或愉悦感。但如果增加太多，就会因过量导致呼吸衰竭。
Opioid receptors, especially the κ receptors, are widely distributed in the brain's respiratory center in hypothalamus. Overdosing can lead to respiratory failure. Importantly, opioid receptors exhibit clear "tolerance." When opioids are repeatedly used, the receptors become less sensitive. At this point, the same dose of opioids is not as effective, failing to produce the same analgesic or euphoric effects. This phenomenon is known as drug tolerance. The tolerance drives users to increase the dosage to maintain the analgesic or euphoric effects. However, excessive dosage can lead to respiratory failure and, ultimately, death.
Another crucial reason for fatalities is when drug users stop using for a period (e.g., for detox, lack of opioid supply, or lack of funds) and then resume use. They may not be aware that after discontinuation, the sensitivity of the receptors gradually recovers. If they resume using the same dosage as before, the dosage becomes significantly excessive due to the restored receptor sensitivity, potentially causing immediate respiratory failure and death. This is why opioid drugs are particularly dangerous for addicts.
美国最近10年的芬太尼之殇 The Fentanyl Tragedy in the Last 10 Years in the U.S.
The history of drug abuse in the United States, across various types, reflects the country's societal issues, which will not be elaborated on here. The U.S. also has a "pain culture" wherein both patients and healthcare providers tend to use medications to control pain, ensuring basic quality of life rather than enduring it. However, the widespread use of opioid analgesics, especially for prolonged periods, has led to a minority of patients becoming addicts. Additionally, until the early 21st century, pharmaceutical companies downplayed the addictive nature of synthetic opioids, and the FDA was not stringent enough in regulating them. However, these issues have seen significant changes in recent years. Although there is still misuse, opioid-related deaths relevant to medical use have not increased significantly.
However, starting around 10 years ago in 2013, the number of deaths due to the overdose of opioid drugs has been steadily increasing. In 2015, it exceeded 50,000, surpassing the number of deaths from traffic accidents or gun violence. In 2017, it exceeded 70,000, and by 2020, it had surpassed 90,000. In 2022, it reached 110,000. Most of these abnormal deaths are not related to prescribed pain medication. Unlike COVID-19, the victims of overdosing on these drugs are primarily young people, many of whom come from small towns in the "Rust Belt" of the United States. These places were once vital components of the American industry. However, globalization has led to their decline, and many young people in these areas have lost their jobs, resorting to drugs to fill the void in their lives.
The curve below subtracts deaths caused by other drugs and specifically shows the annual number of deaths caused by synthetic opioids, mainly fentanyl. From it, we can observe a skyrocketing trend in the number of deaths over the past decade. These cases are almost entirely unrelated to medical treatment, as the drugs are obtained entirely from the black market. Currently, more than 80,000 lives are lost each year in the United States due to fentanyl, and this number is still rapidly increasing. It has become an unbearable burden for the United States. Many years ago, the U.S. referred to this as the "Fentanyl crisis" and emphasized the need for urgent resolution. However, looking at the graph, apart from a slight improvement in the years 2017-2019, the situation in other years is disheartening. The fentanyl problem is not something the United States can solve on its own.
伤天害理的买卖 The Lawless and Immoral Trade
The majority of the fentanyl flowing into the United States comes directly or indirectly from China. Fentanyl is a fully synthetic opioid with mature technology, easily obtainable precursor chemicals, and low production costs. Moreover, fentanyl can be taken orally, eliminating the need for injection like heroin or morphine, making it convenient for "consumers." For a considerable period, China had no legislation specifically targeting these drugs. As a result, the production of fentanyl became a lucrative industry, with many private chemical factories involved. China's "affordable" fentanyl products were shipped across the ocean. For example, 97% of fentanyl seized from international mail to the U.S. originated from China in 2016-2017.
Before 2018, U.S. drug dealers could heinously order fentanyl directly from numerous Chinese websites. They could effortlessly place orders online, and kilograms of fentanyl from China would be sent directly to the U.S. For instance, there was a website in Hangzhou called "Weiku.com," where nearly a hundred companies once sold fentanyl. Each pound cost only one or two thousand dollars, an incredibly low price (combined with fentanyl's high potency). Even with substantial profits at every stage of circulation, the cost to the "consumer" was still low, around $1 per dose. This affordability made fentanyl accessible even to addicts who couldn't afford fast food.
中美的不平坦的合作 Bumpy Cooperation Between China and the U.S.
Many years ago, the U.S. started to urge China to investigate Chinese companies involved in illegal fentanyl production, but China's response was lukewarm. Fentanyl did not pose a risk of abuse in China, so there was not much motivation on the Chinese side to regulate it. In the early days of Trump's presidency, there was a relatively friendly trial period between the two countries. During this time, the U.S. urged China to intensify efforts on this matter. Consequently, China enacted a new law banning the synthesis of opioid drugs comprehensively, dealing a blow to the unregulated fentanyl industry at home and leading to an immediate reduction in the number of deaths in the U.S. The flattened curves from 2017 to 2019 in the two graphs above reflect this.
However, China's increased regulation seemed like a favor to the U.S. When the relationship between the two countries soured due to trade wars, U.S. criticism of China's human rights, and disputes over the Taiwan issue, effective cooperation quickly stalled. Consequently, the fentanyl trade became active again.
Now, since direct manufacturing and export of fentanyl are illegal in China, illegal elements found alternative ways to profit. They began cooperating with Mexican drug cartels. Since 2019, in most cases, they smuggled precursor chemicals to Mexico, where they were illegally synthesized and then trafficked to the U.S. The result has been a sharp increase in deaths due to opioid overdose (mainly fentanyl), reaching nearly 110,000 in 2022, including a small number of medically sourced cases.
As of the summer of 2023, the prospects for cooperation between the two countries on this issue are bleak. In July, Secretary of State Blinken chaired a video conference with 84 countries, hoping to pressure China collectively to take stronger measures to curb the flow of precursor chemicals used to manufacture fentanyl to other countries. Subsequently, U.S. federal prosecutors announced the indictment of four Chinese companies, accusing them of illegally trafficking chemicals, which were then used by Mexican drug trafficking groups to manufacture large quantities of fentanyl destined for the U.S. Some U.S. lawmakers also strongly criticized China on this issue, accusing it of irresponsibility.
In response, "China does not buy it." For example, on July 27, the People's Daily published an editorial stating, "On the issue of drug control, the U.S. must face its own problems and not shy away from them. Attacking and smearing China cannot cure the chronic disease of drug abuse in the U.S." For a while, domestic media fiercely countered U.S. accusations, blaming the U.S. for attributing its social problems to China, making it widely known domestically. When I called my parents in China, they asked me about fentanyl and why Americans blame China for drug addiction.
筹码与回报 Chips and Returns
Just over the past three months, the relations between the two countries unexpectedly warmed. Both sides felt that coldness and confrontation were not their best interests. So, Xi and Biden shook hands again, each harboring their own wishes. It is indeed true that "nations have no permanent friendship or hostility, only permanent interests." Many find this saying distasteful. However, taking care of interests does not necessarily mean sacrificing basic moral principles. In this regard, I have confidence in the United States.
Regarding the fentanyl issue, neither the Chinese government advocates the production and export of fentanyl, nor does it force the drug into the mouths of Americans. Moreover, China has completed legislation on paper. Therefore, the Chinese government can claim to be clean. The fentanyl issue can be used by the Chinese government as leverage. How much effort China will put into helping the U.S. solve the fentanyl problem depends on the returns it gets, including compelling the U.S. to make concessions in areas of interest to China or requesting the U.S. not to embarrass the Chinese Communist Party in certain matters.
Two days ago (November 16th), the U.S. government removed the Chinese Ministry of Public Security's Forensic Identification Center from the Department of Commerce's trade sanctions list. The institution was listed in 2020 for allegedly violating the rights of the Uighur people, and China has been quite unhappy about it. Simultaneously, the China National Narcotics Control Commission issued a warning to domestic industries related to the production and sale of substances that could be used to manufacture drugs. Chinese officials also stated that they should not be confined to the "long-arm jurisdiction" of foreign law enforcement agencies. The official stance is that China took the initiative and did not act because of external pressure.
Interestingly, Biden continues to refer to Xi Jinping as a "dictator." Although this term carries some negative connotations, it's not that bad; it essentially means "holding supreme power," as Xi himself stated. An advantage of such a system of holding-supreme-power is that, under the leader's jurisdiction, if he truly wants to stop certain behaviors (although he may be powerless against a virus), he can certainly achieve it. One or two years later, data from the U.S. will tell us how well he has done.
The meeting took place at a wedding hall in San Francisco. I wonder if Wang Yang has any new rhetoric on this. According to reports, during the bilateral talks, Xi and Biden took a walk in the yard during the break, without a translator. So everyone is curious about how the two communicated. In my opinion, if they have “mind-meld” with each other, eye contact is probably enough; on the other hand, if they are like a chicken and a duck being stuffed into a cage, then even with eight translators, it's futile.
[manually edited from ChatGPT translation.]
It seems the US government is always blaming others for its citizens' addictions.
DEA：Fentanyl is the greatest threat facing Americans today. It is a threat to our public health, our public safety, and our national security, and it is the cause of the most devastating drug crisis in United States' history.
If it becomes that bad, simply send 101st Airborne division to those states with serious drug problem.