For over a decade, epidemic fentanyl addiction has been a mass casualty crisis, and a significant—if not primary—contributor to the rot of every major city in the country. If there exists a will among our political class to solve this problem (admittedly questionable), our local officials certainly haven’t found a way. Fortunately, there now exists a wild potential solution. Long story short? Scientists have developed a fentanyl vaccination. Next uncomfortable question: should addicts be asked, pressured, or even forced to take it?

For my part, the idea of children, or even healthy adults being asked, let alone pressured to undergo a new treatment strikes me as clearly unethical. But were a convicted drug offender offered a quick way out of prison in the form of a cure to his own addiction? That’s a different question, and I’m not sure I hate the notion.

Nick Russo guests for Pirate Wires with a piece on the new vaccine, the early whispers of strategic thinking surrounding administration of the drug, and the many fraught ethical questions at play.

-Solana

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Crisis. On November 8, 2022, the Mexican government unveiled a national ad campaign designed to scare the country’s youth away from drug use. The flagship video featured a smorgasbord of by-now all too familiar scenes of urban devastation amid the opioid crisis—emaciated drug users slumped over on the sidewalk, nodding off mid-high, against a backdrop of tent encampments and trash-strewn streets. But for some American viewers, the scenes went beyond mere visual familiarity and evoked an uncomfortable realization: wait, I’ve been there before… holy shit, that’s the El stop at Kensington and Allegheny in Philadelphia.

The irony here is hard to miss: the main drug ravaging the featured section of North Philadelphia is fentanyl, much of which is smuggled across America’s southern border by Mexican drug cartels. From that border, distributors transport the drug all over the country; the footage used in the ad campaign could just as well have come from San Francisco’s Tenderloin District. And while the misery wrought by fentanyl is most visible in concentrated urban settings, neighborhoods in major cities are far from the only American communities being sucked into the void by addiction.

From Maine to New Mexico, fentanyl overdoses are skyrocketing nationwide. By May 2021, for the first time in history, over 100,000 Americans had died of opioid overdoses in the preceding twelve months, which is more than gun violence deaths and traffic fatalities combined. This surge has been fueled primarily by fentanyl.

The American institutions responsible for abating this crisis are reeling. From federal, state, and local law enforcement to medical centers to social workers, everyone seems powerless in the face of fentanyl.

Its potency is its power. Since so little is required to get high, manufacturers can supply the entire American market for a year with only three to five metric tons, and traffickers can reduce risk by smuggling smaller quantities. A 2019 border security plan with $564 million earmarked for enhanced non-intrusive inspection technology (such as X-ray imaging systems) has thus far proven futile. Congress aimed to significantly ramp up vehicle inspections at the border, but it turns out that even if we seize marginally more fentanyl, cartels can easily absorb the losses.

As such, a 2021 bipartisan congressional report asserted “the impossibility of reducing the availability of illegal synthetic opioids through efforts focused on supply alone.” It therefore posited we need to reduce demand. But it simultaneously asserted “existing treatment regimens and public health programs are not sufficient to stem the rising tide of fatalities.” It issued a call to “bolster appropriate harm-reduction interventions to prevent fatalities and give people with substance-use disorder more opportunities to enter high-quality treatment.”

So our two prevailing paradigms for combating drug crises—war-on-drugs and harm reduction—and the whole slate of institutions operating under one or the other, are woefully inadequate. Without a major paradigm shift, the report concluded, a grim future is in store for our nation:

Failure to intervene in ways that appropriately reduce demand and decrease the risk of fatal overdose will almost certainly result in the deaths of hundreds of thousands more Americans and will imperil the country’s economic and social well-being.

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The silver bullet. “I am proud to be at the University of Houston today,” said Texas Governor Greg Abbott on December 1, 2022, “to celebrate the brilliant achievement of Dr. Colin Haile and his research team on creating a fentanyl vaccine. This incredible, groundbreaking new therapy has the potential to revolutionize how we combat fentanyl deaths in our communities and end the afflictions of addiction that burden so many innocent Texans and Americans across the country.”

There’s your paradigm shift.

Haile’s group has developed a vaccine that prevents rats from feeling the euphoric effects of fentanyl without inducing any notable adverse side effects. It also prevents rats from overdosing, and both benefits are expected to translate to human recipients. In the coming months, they will begin manufacturing clinical-grade vaccines for use in human trials. 

The vaccine works by stimulating the production of antibodies that bind to fentanyl and prevent it from entering the brain. Those antibodies do not cross-react with other opioids, meaning vaccinated subjects can still receive other therapeutic drug treatments, and they remain in the body at sufficient levels only for a period of months after vaccination, meaning boosters are required to maintain preventative effects. Experts tout the vaccine as a means of relapse prevention; if recovering addicts cannot get high as they try to get back on the wagon, the rate of relapse (which is presently astronomical) should drop, so that over time fewer and fewer people will be actively addicted. It’s the perfect weapon for a demand-reduction arsenal.

Haile’s is the first effective fentanyl vaccine, but not the first that works against addictive drugs. A cocaine vaccine has existed for decades. Vaccines for nicotine, meth, morphine, and other opioids like oxycodone are in preclinical or clinical development. As such, medical professionals and policy experts have long been pondering how best to put these powerful tools to use.

Thus far, discussions have largely revolved around two questions. First, should drug vaccines be used merely to treat addiction, or also to prevent it? And second, should vaccination be purely voluntary, or are there circumstances under which it should be mandatory? A 2014 Nature article delved deeply into both questions, which often bleed into one another.

For instance, the authors noted that some proponents of the prevention approach “have advocated incorporating vaccines against addiction into compulsory state-mandated statutes for the immunization of 11- and 12-year-old schoolchildren.” If addiction ruins lives, the thinking seems to go, why risk it? No young person need ever overdose again if we simply eliminate getting high from the range of possible human experience.

True, the authors observed, such a mandate would be unprecedented, because to date all required vaccines prevent the spread of contagious diseases, whereas addiction puts only the addict’s life in danger. Or does it? “Social-contagion theorists,” they noted, “have shown that one person's behavior is very likely to influence the behavior of others, which suggests a more 'infectious' disease model for addictive behavior.”

They went on to discuss the “ethical principle of respect for autonomy,” which a vaccine mandate clearly violates. Except maybe it doesn’t, because “in dealing with addicted patients, the parameters of this principle can be ambiguous, especially if temporary restrictions on a patient's autonomy could create more autonomy in the long term.”

Granting that universal childhood drug vaccine mandates might not be well-received by the public, they turned their attention to specific subpopulations for which mandates would be more politically palatable. For example, we could impose vaccine requirements on “those eligible for parole or those who accept welfare.”

Ideas like this transcend the Nature piece. A 2022 Seattle Times article has an NIH director saying she could imagine an opioid vaccine being used by people in prison, since former inmates overdose at shocking rates. A 2019 Filter Magazine article has a drug policy scholar at the University of Washington-Tacoma asking: “Will a vaccine be a requirement for someone with [substance use disorder] who seeks housing? Will drug courts mandate vaccines?” And a survey of pharmacists published by BMC Medical Ethics in 2021 shows that support for opioid vaccine mandates is highest for those who’ve overdosed or been sentenced in drug court.

Even these more targeted mandates would likely face stiff resistance in the arena of national politics. But, having just lived through the COVID pandemic, we’re all too aware that unprecedented times are often used by policy makers to justify unprecedented measures. And the analogy between COVID and opioid addiction is already being drawn. It’s a simple one: the opioid crisis, like COVID, is a public health problem of epidemic proportions. If widespread vaccine administration dramatically reduced COVID mortality, couldn’t it do the same for opioids? And then: if mandates could boost vaccination rates and save tens of thousands of American lives, aren’t they a no-brainer?

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The thin line. A fentanyl vaccine mandate, then, is at least politically conceivable in 21st century America. Human clinical trials are on the horizon, and the intellectual groundwork for a mandate has been laid. There is widespread bipartisan recognition not merely of the severity of the fentanyl crisis, but of the futility of cracking down on supply. We need to reduce demand, and a vaccine gives us the power to do it. 

The only question is how we’ll use it: voluntary vaccination, which would likely take longer to deliver milder results, or some form of mandate, which might rapidly and dramatically reduce overdose deaths. Given the grim nature of the crisis—overdosing babies and urban hellscapes—it’s tempting to jump at the mandate. With the full force of the state behind it, the fentanyl vaccine takes on the image of the fully loaded infinity gauntlet; wielding it, we could snap our fingers, Thanos-like, and transform the potent killer into baking soda overnight.

But it’s precisely because this seizure of power is so tantalizing that we need to be careful here. Fentanyl vaccine mandates could be abused, and their underlying justifications could be leveraged to usher in further abuses of power.

Consider first its use to target at-risk groups. If a fentanyl vaccine were required to access welfare and housing, it’s not hard to imagine that those deepest in the throes of addiction would refuse it and thereby lose out on desperately needed material aid. The country ends up with an even more deeply entrenched class of homeless addicts who fuel their drug habits with petty crime. The overall number of overdoses declines, but existing urban hellscapes solidify.

Maybe we mandate that anyone resuscitated from an overdose on the street receives a vaccine along with their dose of Narcan. Or even anyone caught using or carrying fentanyl. Tens of thousands of vaccines are administered against the will of the recipients. Many of them enter recovery. This is great news, especially given that the fentanyl vaccine has no known adverse side effects—for now. But what if that changes, like it may have for COVID?

Maybe we mandate anyone convicted in drug court must receive the fentanyl vaccine prior to release from prison or as a condition of parole. Periodic boosters, too, such that drug offenders are forever biomedically monitored by the state. The program is so successful we start to wonder what other public health mandates we tack onto it to save American lives. Remember, one person’s behavior is likely to influence the behavior of others, and some restrictions on autonomy actually create more autonomy in the long run. Using this logic, we could justify a plethora of state-mandated biomedical interventions as conditions of parole. If present online censorship trends continue—e.g., the silencing of professors who argued COVID policies would have pernicious effects on children—who knows what “adverse side effects” of mandatory biomedical interventions could be suppressed in the name of saving lives.

Here, we glimpse the rise of an immensely powerful, one-party-state-backed, prison-pharmaceutical complex.

In short, existing arguments in favor of a fentanyl vaccine are just as applicable to any number of intrusive treatments designed to mold the traits and behaviors of the public. There is no major political party in this country with respect for constitutional rights or civil liberties. Any policy that can be sold to a constituency, will be.

On the other hand, it's also conceivable a fentanyl vaccine could free our cities from the pernicious effects of effete and deranged ideological rule. Imagine what a progressive prosecutor, like Philly's Larry Krasner, could do with it. By incorporating the vaccine into pre-trial plea negotiations, he could be a bit tougher on the people he's been letting off the hook completely—i.e., the ones school children see shooting up on the sidewalk every morning—without sending his staunchly anti-mass incarceration base into hysterics. The cops start hauling drug users off the street, turn the cases over to Krasner, and his prosecutors offer a deal: take the vaccine and we'll let you walk; don't, and go to trial.

America is reeling from opioid overdoses. A fentanyl vaccine is just over the horizon, and our leaders will have to decide how to implement it. The decision deserves all the scrutiny we can muster.

It’s a thin line between silver bullet solution and totalitarian spiral.

-Nick Russo