The Iron Law of Prohibition

When things aren’t going well, people always look for a scapegoat. When it comes to the opioid epidemic, the CDC’s preferred scapegoat has been pharmaceutical companies. Meanwhile, the DEA blames doctors for over-prescribing pain medication, and has tightened regulations on the quantity that can be prescribed. As we’ve learned from Dr. Jeffrey Singer over the years, the crackdown on prescription opioids has missed the mark and made the problem worse: addicted patients have turned to the black market to satisfy their demand, and gotten hooked on far more dangerous drugs like illicit heroin and synthetic Fentanyl. Singer calls the misguided war on opioids a “war on pain patients” with no end in sight.

More recently, Republican politicians have tried to score points against the Biden administration by scapegoating illegal immigrants for the problem of Fentanyl smuggling. Smuggling has indeed increased. However, a Washington Post op-ed by Cato scholars Singer and David Bier (associate director of immigration studies) reveals the folly of the Republicans’ accusations. Illegal immigrants are not the ones bringing Fentanyl across the border, they note. It’s mostly US citizens doing the smuggling. Ever since border enforcement has tightened, it has become more common for smugglers to conceal small amounts of the much more potent Fentanyl in otherwise legal border crossings.

David and Jeff join the show of ideas to discuss the inevitable unintended consequences of both the war on drugs and the war on immigrants. We investigate the issue from the angle of the failure of drug prohibition, as well as the failure of strict immigration policy. Both of these problems share a common root cause – they seek to interfere with free markets. The laws of supply and demand don’t stop functioning just because an artificial legal boundary is erected – whether you’re talking about drugs or people.

The solution is simpler than you think – but first, we must assign the blame correctly.

Will politicians examine their own role in creating the crisis and reform the system, or will they continue to scapegoat innocent people?

Transcript

Bob Zadek: Hello, everyone. I'm Bob Zadek, host of the country's longest running libertarian broadcast. Nationally streamed 8 AM Pacific Time Sundays on the 860 AM app. My podcast contains more than a decade of historical issues. bobzadek.com offers resource material, book lists, other topical podcasts, and much, much more. We strive to offer in-depth content on social, political, and economic issues that really matter always and always with the ideal guest, accessible and entertaining. Our rule - ideas, not attitude

In today's show, I'll seek the help of two experts to understand and perhaps solve two surprisingly related but intractable nationwide problems, which seem to justify solutions and are laden with misunderstanding. The flood of black-market fentanyl on the one hand and our open southern border, in fact, all of our borders on the other hand. Is there a connection with the crisis at the border and with street fentanyl seeming to flood cities large and small in our country? Is there a connection, is one the cause of the other? We have to find this out. I'd like to welcome back to the show, Dr. Jeffrey singer.

Jeff is a senior fellow at the Cato Institute and a practicing general surgeon. And also, welcome to the show, yes, we have two guests today, David Bier. David is associate director of immigration studies at the Cato Institute. Gentlemen, welcome to the show this morning.

Jeffrey A. Singer: Thank you.

David J. Bier: Thanks for having me.

Why Fentanyl Smuggling Doesn’t Come from Illegal Immigrants

Bob Zadek: Now, my first question to David. We're going to try to help our audience unpack these somewhat complex issues. And we're going to try to undo a lot of the, and the word that we hear in the news all the time, much of the misinformation about the border, in general, the open border and specifically whether or not the open border contributes to or has any relationship to the fentanyl crisis.

So, David, you have written quite a bit on this. What, in your view, as you observe what commentators are saying and what bloggers are writing, is the claimed relationship between the crisis at the border, our inability to control our borders, and the flood of black-market fentanyl? What is the perception in the public as you see it about the connection between open borders, immigration, and fentanyl?

David J. Bier: Well, it's pretty clearly stated that illegal immigrants are bringing fentanyl into the United States and selling it to Americans who are dying as a consequence of that. And it's because we don't have enough Border Patrol, it's because we're not enforcing our immigration law strictly enough that people are dying in the streets, or in their homes, or wherever as a result of this surge in production, and trafficking, and fentanyl.

Bob Zadek: So, as a result of that perception or misperception, are you concerned that there might be some animus directed towards open borders in general? That is to say open borders or welcoming immigrants are in and of itself as a policy contributing to the fentanyl crisis. Does that seem to be the perception that our thought leaders and bloggers or many of them are presenting and is there any connection between the two in your studied opinion?

David J. Bier: Well, first of all, yes, I think members of the public are being told that asylum seekers, people who are seeking asylum in the United States because they have a fear of return to their home country are contributing to the fentanyl crisis and that we need to end asylum in this country immediately, expel people back to either Mexico or to the country that they're fleeing from. We've seen this repeatedly used as a justification for policies that are not talking about, whether we stop someone from crossing illegally. It's about whether they can actually apply for a status in this country once they're already in custody. And if they're in custody, obviously, they search for fentanyl.

At the base of it, there is the truth underlying this narrative is that most of the fentanyl coming into the United States now is coming from Mexico. The misperception is that it is primarily being trafficked into the United States by illegal immigrants crossing the border illegally. That is entirely untrue. This is supported by the department-- Every law enforcement agency in the federal government knows that this is the case. They testified before Congress on this issue this year – every single Customs and Border Protection, the Drug Enforcement Administration, the FBI – they all agree that the way that fentanyl and almost all other hard drugs enter the United States is through legal ports of entry where legal travelers are bringing fentanyl in their luggage, in cargo.

It's really easy, because fentanyl is so potent that it's easy to conceal. Whether with your luggage, or in a package, or as part of a large shipment in legal cargo, it's very easy to bring it in. And so, that is why it makes more sense from the standpoint of a cartel or a drug trafficker to try to bring it in through these legal entry points, then it is to try to sneak across the border with it on your back, because the rate of apprehension, the rate of detection of people crossing the border illegally is actually much higher than people think it is. We have actually very good surveillance now. We have drones 24/7 in the skies, we have cameras all along the border. Of course, we don't catch everyone, but we actually do have a pretty good idea about the total flow.

The rate of apprehension is greater than 50% and the rate at which we're intercepting fentanyl coming into this country is below 5% and it has been for years. And so, it doesn't make sense from the standpoint of a drug trafficker to choose trying to sneak into the country with fentanyl compared to trying to sneak it in through a legal crossing as part of their luggage.

The Iron Law of Prohibition

Bob Zadek: Now, Jeff. Dr. Singer – fentanyl, there is so much misunderstanding about what fentanyl is, why it's a crisis, and why are we reading about fentanyl, all of a sudden, so much in the news. There was a time fentanyl was never spoken anywhere. So, help us understand, first of all, the big picture of why fentanyl became in the news at all? Was it filling an unfulfilled need?

After all, we had lots of stimulants, lots of other illegal drugs before there was fentanyl. So, why all of a sudden is fentanyl in news to the exclusion it seems of other of the drugs we're accustomed to reading about such as heroin, marijuana to some degree, cocaine and the like? How did fentanyl get to be in the news so much?

Jeffrey A. Singer: Well, I think I'd like to start off by saying for those of your listeners who haven't heard of this term, drug policy experts use the term “the iron law of prohibition.” Basically, any economist understands this, but in shorthand, the harder the law enforcement, the harder the drug. So, fentanyl has been around since the 1960s. It's a synthetic opioid, which means there's nothing derived from the pop opium plant. It's made in the lab. So, very useful, effective opioid that we use in the operating room, we use for anesthetics, we use people in intensive care, we use it usually in an injectable form, sometimes this is a skin patch called Duragesic that we use, which is slowly absorbed through the skin over a few days. So, it's a very useful painkiller.

Fentanyl is about maybe 50 times the potency of heroin. And heroin is about twice the potency of morphine. So, it's about hundred times the potency of morphine. Very potent. And therefore, a very small amount can get a lot of bang for the buck. When drug prohibition tends to make people who are in the business of making or dealing drugs try to come up with more potent forms of the drug, because it makes economic sense. If it's potent, they could smuggle it in smaller mass- [crosstalk]

Bob Zadek: Jeff, I want to interrupt in just so the audience can follow. You say it's a potent drug. It's more potent than morphine. Potent in what extent? What does it do better or stronger or more effectively than other drugs? Potency at doing what?

Jeffrey A. Singer: Okay. It's a much stronger narcotic. It gives you a much more rapid euphoria, but it also because it's so strong, a small dose could be enough to make you stop breathing, whereas less potent opioid would require a much greater dose to reach the level where you would stop breathing. But because of prohibition, it makes sense economically. If you can figure out a way to make something more potent, then you can smuggle it in more easily, because a much more effective amount of it could be made in a smaller size, so you could sneak it in.

For example, in your suitcase, illegal border crossing, and show them your US passport, and just get right in. And also, when you finally get across the other side, since it's so potent, it can be subdivided into multiple amounts and sold. And therefore, we can get more bang for the buck. It's because of the iron law in prohibition that marijuana has gotten stronger – THC concentration over the years – it’s why cocaine use developed into crack cocaine and it's why heroin has now become fentanyl.

Particularly, it was exacerbated during the COVID pandemic, because supply chain issues developed and heroin is processed from the opium poppy. There are certain chemicals that you need to process it, you have to grow it, it was much harder to move it across the normal supply chains during the pandemic. That made fentanyl even more attractive to drug dealers, because the ingredients to make fentanyl were available and can be much more easily made in a lab more quickly. So, it's quickly became the go to substitute for heroin. And I've got to give everybody a warning. In a year or two, we're going to be talking about nitazenes, because that's how the iron law of prohibition works. Already, since 2019, we see increasing reports of overdoses from a class of synthetic opioids called nitazenes, which were developed in 1950s by Ciba-Geigy in Switzerland and it's about 20 times more potent than fentanyl and it never went to market in this country. Lately, we're starting to see that appear in a large number of overdose deaths. Just recently, a state of Tennessee Department of Health reported on it and it's being seen in Europe.

“It's because of the iron law in prohibition that marijuana has gotten stronger. It’s why cocaine use developed into crack cocaine and it's why heroin has now become Fentanyl.” – Dr. Jeffrey Singer

Again, the iron law is continuously making drug dealers want to find an event more potent forms of the drug. If you really want to put the blame for the fentanyl crossing into our country and flooding the United States, it should really put the blame on prohibition.

David J. Bier: I just wanted to add one thing to that that really highlights this transition during the pandemic that Customs and Border Protection tracks their seizures of fentanyl and heroin. Basically, these are feeding into the same market. At the beginning of the pandemic, about a third of their seizures were fentanyl. By the end of the restrictions on trade and travel with Mexico, 90% were being intercepted was fentanyl. The restrictions at the border preventing trade, and travel, and free crossings really had a huge effect in shifting that black market away from heroin, which is less potent to something that could supply the same market with 50 fewer trips. And that's what makes sense from an economic perspective for the drug trafficking organizations. So, we played right into their hands in creating this crisis.

What Caused the Rise of Fentanyl

Bob Zadek: Now, a question to either one of you, perhaps to Jeff first and then David. What was the externality that invited fentanyl into the marketplace? Because there was a period of time that, when you heard about or read about the drug problem, the nouns were cocaine and heroin. 20 years ago, my dates could be off, you weren't hearing about fentanyl at all. Was there an external event, either a change in demand or was there governmental action or inaction that causes fentanyl to enter the marketplace after all supply exists to satisfy a demand?

Is it in only public taste or fashion, or is there something that caused fentanyl to become so much in demand? Because after all, it's the demand that creates the supply coming into as we all know.

Jeffrey A. Singer: Well, actually, Professor Dan Ciccarone at UC San Francisco Medical School, he's an addiction specialist. He has been doing a lot of research for the NIH. It is a project called The Heroin in Transition project, where they're actually interviewing intravenous heroin users on the street. What he reported was that most IV drug users prefer heroin. That's a completely different feeling you get. To quote him, he spoke at Cato conference, I'm paraphrasing now that he said, "Heroin is warm and fuzzy, whereas fentanyl is bold and brash."

Most people seek heroin, I mentioned before the iron law of prohibition and then exacerbated by the border restrictions, it's gradually become more economical for the cartels to supply the market with fentanyl. And now, over time, some heroin users have just gotten used to using fentanyl instead, but most of them, if you gave them a choice, they prefer heroin and they'd like to know if there's fentanyl and heroin, because they want to adjust their dose accordingly.

Another interesting phenomenon, and this I learned recently from somebody here in Arizona, who runs a Harm Reduction Organization, that a lot of the fentanyl coming across the border here in Arizona and probably in California is in a pill form now. They're making them as pills. They used to come more in powder or mixed in with heroin so they can make the heroin more potent and smuggle in smaller sizes. A lot of the drug users find that it's not very easy for them to make those pills into an injectable form. So, they've gone to smoking them. In fact, this person I spoke to operates a needle exchange program and she says, "We need fewer needles and more safe smoking equipment, because the users tend to share glass pipes that are cracked, and they give each other cuts, and spread infection."

But on the other hand, from a doctor's perspective, it's actually safer to smoke it, because usually you calibrate the dose you get to the desired effect. When you take it, take a couple of ventilations and when you reach the desired level of effect, you stop. Whereas when you inject, it's all in you. If it's more than you needed, it's too late.

The COVID Shift: When Fentanyl Started Coming from Mexico

Bob Zadek: Now, David, in the relationship between the influx of fentanyl through all say the southern border, I suppose that's the more active place. If you were to chart out the influx, was it at one time heavier and enforcement made it less likely to occur, because the likelihood of getting caught was greater? Or was the alleged flow of fentanyl through the southern border never very much and the fear that's flowing through this open spigot was that manufactured? So, tell us if you will, by quantity, a brief history of the relationship between the flow of fentanyl over time.

David J. Bier: About five or six years ago, most of the fentanyl that was coming into the country seemed to be coming in from China through the mail. China really cracked down on fentanyl production and its country made it more difficult. So, supply shifted directly to Mexico and really ramped up since then, because it was easier to shift bulk for Mexico than it was to bring it in through the mail. It seemed that had an effect on shifting the market. And so, we saw every year from 2015 to this last year, increasing rates of fentanyl being intercepted at the border. Again, 90% of it at the illegal crossing points, maybe 10% or so coming across the border illegally, but both heading north every year.

“We saw deaths from fentanyl double from 2019 to 2021, when this policy of restricting immigration started, as a result of this shift in the market.” – David Bier

But in 2020, there was a fundamental shift and it happened at almost immediately, April, May, June, July of that year, when basically illegal immigration plummeted at the beginning of the pandemic. The South American, Central American countries had locked down their populations. There was very little movement. There are no jobs in the United States to go to. So, illegal immigration was almost eliminated in May of 2020. But the flow of drugs didn't stop. Obviously, people are still demanding drugs. They had also at the same time restricted legal entry, only what they deemed essential travel was permitted from Mexico into the United States. As a consequence, legal crossings plummeted as well.

What the cartels did is they shifted overwhelmingly to using fentanyl and supplying fentanyl, because they could supply the same market with 50 fewer trips and that's a very powerful economic incentive. It happened at the same time that illegal immigration plummeted. We saw deaths from 2019 when this policy of restricting immigration started until 2021, deaths from fentanyl double tragically as a result of this shift in the market.

What Counts as Essential Immigration?

Bob Zadek: David, you're an immigration expert. So, it's appropriate for me to ask you this question. In your last comment a moment ago, you mentioned that there came a time that immigration was restricted only to, and here comes the word, essential immigration. Now, I perked up when I heard that. I had an immediate PTSD flashback to the COVID epidemic. And all of a sudden, the only stores that could be opened were those providing essential services. Essential became this word to hide behind in imposing irrational governmental restrictions and policies. And as you said it, David, I said to myself, "What in the world qualifies as essential immigration?" I must ask you that because I can't answer the question myself. Essential to the immigrant, or essential to the country, or essential to what exactly? And share with us, if you will, what could possibly be the standards by which essential immigration is measured?

David J. Bier: Yeah, at the end of the day, it really just came down to- noneconomic migration was basically prohibited. If you were coming to visit a family member, or to wine and dine in San Diego, or see a wedding, or any normal activities that people would have engaged in before this was banned. Of course, seeking asylum in the United States was deemed non-essential to even those people who might die if they couldn't cross the border. So, they eliminated about 75% of all the entries at the Southwest border over that summer. And that's when the fentanyl trafficking really picked up because it was much more difficult to bring in the same quantity of heroin as in the past. But ultimately, the market found a way to supply the same users as before. It was just a different substance and it had pretty tragic consequences, because no one was prepared for that shift in the marketplace.

The Tragedy of Shifting Demand to Fentanyl

Jeffrey A. Singer: Now that those restrictions have been lifted, it's not as if the cartel's going to go back to, "Oh, good. Now, we can start moving heroin across the border," because they've learned that it's much more economical for them to move fentanyl. And even though many users in the United States might prefer heroin, they've gotten accustomed to using fentanyl. If you gave them a choice, they may choose the heroin over the fentanyl, but fentanyl, at this point they've just adjusted to it.

Bob Zadek: Now, perhaps, a naïve question. Is so much of the fentanyl imported, brought across the border illegally, because if you try to manufacture it in the US, you're likely to get caught or is it because it's cheaper to manufacture outside the US? Why is fentanyl not like moonshine just grown in the hollows or manufactured in the hollows? Why imported versus manufactured in the US?

Jeffrey A. Singer: Well, first of all, of course, illicit fentanyl is manufactured in the US. There are pharmaceutical companies that make fentanyl for use in a hospital in the medical setting. And the Drug Enforcement Administration sets quotas on how much of every single category of painkiller of controlled substance whether it's fentanyl, or morphine, or oxycodone, they actually are charged with having to decide for the next year just how much of every single one of these things. The United States with a population of 330 million people will be needing that year and they tell each company this is how much you can make that year, which of course is an impossible thing to be able to figure out. But it's obviously easier to make more cheaply and out of the view of law enforcement outside of this country and you can cobble together the ingredients you need to make it there.

Bob Zadek: So, Jeff, that sounds like a counterproductive policy. I'm sure it is. But the somewhat obvious question is, if that limitation were not imposed, if the government did not limit how much could be manufactured creating an artificial shortage by governmental action. Do you imagine that the amount of imported fentanyl across the border would diminish?

Jeffrey A. Singer: No.

Bob Zadek: So, there is no relationship between- [crosstalk]

Jeffrey A. Singer: No, I was just saying that it is made in United States, the illicit fentanyl.

Bob Zadek: Then why import it?

Jeffrey A. Singer: The same reason that methamphetamine which is by the way a legal drug that's made in the United States, it's used to treat ADHD. The brand name is Desoxyn. But methamphetamine is made in meth labs mostly in Mexico now. Originally, there were a lot of local domestic meth labs, but it's easy to do it out of the purview, out of the sight of law enforcement when you go south of the border or not necessarily even southward – elsewhere, outside of the country offshore, because otherwise, law enforcement is always trying to surveil you. So, it's for that reason that it's been driven out of this country.

The Need to Manufacture an Illegal Immigration Crisis

Bob Zadek: Now, David, Is there any relationship between what we do at the border, what our policy is as a nation on and on the quantity of fentanyl that ends up on the streets? I started my show by inquiring into the link, if any, between immigration and fentanyl. Many of the public and a lot of policy makers would have us believe there's a relationship. Is there any relationship whatsoever or is fentanyl merely being used as another argument to support restrictive drug policy, but in reality, it's a false argument?

David J. Bier: Yes, it's absolutely a false argument. We already mentioned examples of how border policy can make the problem worse. Restricting it to essential travel, reduce the number of crossings which made it more likely that fentanyl would be smuggled. But the reality is that 86% of drug traffickers who are convicted are US citizens. And that statistic is people poo-poo that and they say, "Well, the immigrants all get away with it." I laugh. There aren't magical immigrants out there. If there was some way to get away with it, you’d see US citizens crossing the border illegally with fentanyl rather than trying to smuggle it through a port of entry, if it was so easy to do that and they're not.

I think it's people who are so committed to making this tie and wanting to impose restrictive immigration policies that they're willing to latch on to this argument to make it more serious. It doesn't seem very serious to people. If someone comes across the border and takes a job at a farm and picks fruit to supply the US market, that doesn't seem like a crisis that justifies radical action against immigration. And so, people have to come up with this fentanyl tie in in order to make people upset about people who are trying to help this country, produce more things, and bring down inflation, and accomplish a lot for this nation. And yet, they latch on to this unrelated phenomenon largely driven by US consumers, traffic by US citizens. Yeah, it's fear mongering and it's based on really an incomplete picture or an absence of knowledge about the facts of the situation.

“If we had actual open borders, we would not have a Fentanyl crisis. It wouldn't exist. There was no natural demand for it initially and it only exists as a method to avoid being intercepted at the US border.” – David Bier

Jeffrey A. Singer: What's driving the fentanyl is the market. There's a demand for drugs and we have drug prohibition. So, the demand is going to be met through the black market rather than through the legal market, period. Now, the only way that immigration ties in is that restrictive immigration activates the iron law of prohibition. Were it not for such restrictive immigration, perhaps fentanyl would not have emerged as a practical substitute for heroin. The tighter we make the immigration, the more we're giving an incentive for the drug makers and dealers to try to come up with something that they could even make in smaller quantities and get much more economic value for smuggling. So, in that respect, our current restrictive immigration policy is stimulating the development of drugs like fentanyl or even stronger drugs.

Bob Zadek: Oh, that's such an interesting link that you pointed out, Jeff.

David J. Bier: If we had actual open borders, we would not have a fentanyl crisis. It wouldn't exist. There was no natural demand for it initially and it only exists as a method to avoid being intercepted at the US border.

A Case Study in Unintended Consequences

Bob Zadek: David, it seems to me that those who oppose a more liberal immigration policy reach into their toolbox and they raise as many arguments as they can, none accurate. For example, we all have heard, "They take our jobs." How absurd is that? That's one argument.

Another argument is, "They create more crime." We know that's not true. Another argument is they dilute American culture. I hate that argument more than others. There's this litany of all fake arguments. Is fentanyl just another one in a series of bad arguments used to justify a policy that cannot otherwise be justified on the merits or is there any truth at all to the fentanyl or is it proper to lump it up with all the other phony arguments against immigration?

David J. Bier: Oh, it's even more phony than the others, because the restrictive immigration policy as we mentioned makes the problem worse. They're actually making the situation that they claim they want to solve even worse by restricting immigration. It's even more absurd and inaccurate than those other ones that you listed. At least restricting immigration, I don't even know what the good comparison would be. But this idea that fentanyl is a reason to restrict immigration makes no sense. It's not logical. And at the end of the day, if you want to clean the slate of border patrol, so they can surveil every hour of every minute, let people come into the country legally. But they don't want that policy. They don't want people to check in and cross the border illegally and come in and contribute to this country.

Bob Zadek: The hardest question I have, I'm speaking personally now about those who oppose immigration or more liberal immigration policy, is there one identifiable group, some unifying factor that describes why so many people are appeared to be opposed to a humane, rational, liberal immigration policy? To be sure, unions have an interest appear to be protecting American jobs. It's fake, but they have it. But that's a clear, defined economic interest. But the opposition and I'm really asking you deep question, David. The opposition is broader than just union members. Is it simply a question of Bootleggers and Baptists, a whole bunch of disparate groups find this unifying issue of open borders, or can you identify the source of all of the energy against immigration, or is there simply a whole bunch of separate sources?

David J. Bier: Well, I think there are a lot of separate sources, but I do think the unifying energy is in the chaotic images that cable news and social media spread. It looks like these people are criminals. They're sneaking across the border. They're evading Border Patrol and law enforcement. That doesn't seem like a good thing. It's not a good thing, but the reaction should be that we should be have a policy where people get vetted before they come, they fly on a visa, they get on a plane, they answer like anyone else, they go to a job legally where they're not paid under the table, and they can contribute like anyone else to this country. Not to close the border and crack down even harder, which only creates even more chaos, and more smuggling, and more problems with law enforcement and government spending.

There are so many stories. I see stories every single day where I think that's a real story that's government is spending how much money on people who crossed the border illegally, but it's only because they had to cross the border illegally that were spending this money. And so, people get outraged when they see stories like we're spending $10 billion to house illegal immigrants who just crossed the border. And it's only because they crossed the border illegally that we're spending this money. And so, it's really a self-reinforcing phenomenon. We start with the restrictive policy, it has chaotic elements, we waste a lot of money, people get mad about it, and then they want more restrictive policy rather than curing the problem by focusing on the underlying immigration issue.

What part of illegal immigration do you oppose?

Bob Zadek: The way I like to explain it, if I'm having a chat with somebody who says the platitude, "I oppose illegal immigration," well, that's a tough one. Okay. I oppose illegal immigration. My retort is, do you oppose the illegal part or the immigrant part? If you oppose the illegal part, in other words, once you change the law, then you're there with a basket of doughnuts as they cross the border, because you're now welcoming them, because they just became legal? Or is it the immigrant part that you oppose and you use in defense of your position the fact that it's illegal? You have just expanded upon, I think, that issue.

People take refuge in the fact they're breaking the law. Well, they're breaking the law, because the law that tries to alter natural human behavior that doesn't hurt anybody, those laws will always be broken, because they are contrary to the nature of humans. I think that seems to be your answer that there isn't one cabal. Not one unifying anti-immigrant party that simply is looking for a whole lot of arguments to justify that position. Everybody has a different reason, perhaps because it's so easy, "Hey, it's illegal and that's why I oppose it." That's why they select that.

Now, Jeff, you studied the fentanyl crisis and more broadly, the opioid crisis. We've talked about it on my show many times. Do you say to yourself or to your readers or to those in the audience when you speak, do you point to immigration policy? Does it come up as one of the elements of your discussion of the fentanyl crisis as--? If immigration policy is fixed, then what I'm here to speaking about yourself declines in significance?

Jeffrey A. Singer: No, actually, I don't. To me, immigration is beside the point. Although, like I said, a little bit ago, that restrictive immigration may help fuel the development of more potent forms of drugs to be smuggled. But really the drug overdose problem- I consider it, by the way, it's a drug overdose problem, not a drug problem. It’s also maybe an HIV and hepatitis problem. At bottom, it's really a prohibition problem. Is prohibition that makes all of this dangerous? When we had alcohol prohibition, we had people dying from drinking denatured alcohol and tainted alcohol. We had the development of be gangsters and gang wars. It's the same thing all over again.

Alcohol, it is a very dangerous drug. Actually, pharmacologically speaking, it's much more dangerous than opioids. Opioids don't cause cirrhosis, heart damage, brain damage, or cancer, but alcohol does. And yet, when it was made legal, it's made so much more safe, because you could go into a store, you could see on the bottle what the ingredients are. There's recourse if the manufacturer was lying and it was a higher strength of alcohol or it had impurities in it. So, the whole overdose crisis is a direct result of drug prohibition. And all these other issues are basically exercises in deflection that tried to deflect the blame.

We said in Washington Post article a few weeks ago, first, they were blaming the doctors and the pharmaceutical companies for causing the overdose crisis. And then when it became fentanyl coming across the border, they're blaming illegal immigrants and a porous border. But that's not going to fix it either. You could build an entire wall around this country just look for something much more potent than fentanyl to emerge very quickly. It's all about prohibition.

Bob Zadek: What I have learned from you, Jeff, and I'd like the audience to learn from you as I have, is that part of the health problem, the fentanyl-related deaths in this country is in part because with legal fentanyl manufactured under the controls that our country imposes upon the manufacture and the labeling, very important component, and the labeling of fentanyl as to what it is and the potency, when you have legal fentanyl, the user will be able to make a more informed decision including quantity.

The issue is not to make it more convenient to be addicted or to abuse the product but simply as you had said, the phrase I learned from you quite a while ago, "harm reduction." That by opening up the marketplace to creating the demand, we talked about earlier, for fentanyl which cannot be satisfied with the drug manufactured under the proper controls. You bring in unlabeled who only manufactured fentanyl which means the user is uninformed and cannot control the quantity as much. Explain for a bit as you have for me so many times the relationship when the street is forced to use imported, it could be domestic with but as you pointed out, imported black market fentanyl manufacturing without controls, how that plays out in the abuse and death of fentanyl users?

Jeffrey A. Singer: Well, because it's on the black market, that's what makes it dangerous. You could see what's happened in a number of states now when they legalized marijuana recreationally and there are actually stores you can go into. So, just like nowadays in a liquor store, if you want to talk to the proprietor and ask them about how much alcohol is in this particular product and you could ask all sorts of questions, well, if you go into a marijuana store, you could go up to somebody behind the counter and say, and I've seen this, where you can say, "Look, I'm a lightweight. I haven't really used marijuana in 40 years. So, consider me a beginner. What do you recommend I buy here?" And they'll say, "Okay, well, let me take you over to this case over here. This is very mild, lower THC concentration." And they actually will give you advice on how to use it. That's what happens when things are legal. Then, people can openly share information with one another, they could make arrangements like we all do with- For example, if you're going to be going to a party and you're planning to drink heavily, so you get a designated driver or you call an Uber to get home rather than driving, these are all forms of harm reduction.

Basically, harm reduction is nonjudgmental. The idea behind it is that regardless of whether or not I approve of your choices, I want to see your choices do less harm to you. As a doctor, I say to a lot of my colleagues, you may not realize this, but in an affluent developed country like United States, the overwhelming majority of things that we do is practice harm reduction. If you have a patient who has high blood pressure, mild diabetes, high cholesterol, they're heading down the highway towards a major heart attack, or something like that and you tell them, "If I can get you on a diet and exercise program, get your weight down, and get your blood pressure under control, get your cholesterol down, you won't even need anything for your diabetes." And the person says, "Yeah, I know, but I can't. I love to eat. I hate to exercise. I know I'll stay on any diet for a couple of weeks and then I'll start to revert back to my habits." So, what do you do? You prescribe a blood pressure pill and a drug to keep their blood sugar under better control like metformin and a statin drug to lower their cholesterol. Well, what you're doing is you're practicing harm reduction. I'm not necessarily approving of your lifestyle choices, but I can't control your lifestyle choices and I also have no right to. So, let me do what I can to make it less likely that you're going to harm yourself by continuing to live your life this way. That's what harm reduction is.

The people in this country, particularly you see on cable news who are decrying the overdose crisis and they say 100,000 people died of overdoses this year, the biggest ever, another record. It's going to be a bigger one next year. It's continuing to grow. Well. If you don't want people to die, then you should allow groups to give out things like clean syringes and needles. Obviously, you should legalize drugs. But if you're not going to do that, at least allow people to give out clean needles and syringes, to allow doctors to prescribe methadone directly to patients instead of having to go to prison like clinics. There are a whole host of harm reduction measures that are prohibited by laws in this country, because the lawmakers say, "I don't want to be seen as enabling or endorsing your choice." But really that's not what you should be concerned about. You should be concerned about that these people are dying. And so, that's where the efforts should be placed.

Fixing Our Failed-immigration-policy

Bob Zadek: Now, David, we have only a few minutes left. So, it's time for me to ask the most provocative question of the century, which would take you about a semester to answer. That's my usual trap that I do with guests. I'll try not to do that. But, David, the immigration policy in this country is, looking at the past, unsolvable. Congress is unable to act, deferring to the president using alleged executive powers. Now at Cato, you publish so much valuable information about what's wrong with immigration policy. Now, what is the low hanging fruit? The somewhat attainable changes that you can see so that our listeners, when they understand the contribution to the fentanyl problem and to a lot of the country's ills, it's almost a hyphenated word "failed-immigration-policy". What are the some of the easy solutions that are attainable that you would recommend that we focus on?

David J. Bier: If I could tell you what is attainable, then I would be a very, very-- [crosstalk]

Bob Zadek: You'll be a guest on my show.

David J. Bier: Look, there's problems all along the immigration spectrum. The physician shortage in the United States is severe. Everyone knows it, everyone agrees on it. This should be something that Congress should be able to take care of it. It ties into the health care crisis, mental health crisis in the United States. We do nothing about it year after year after year. We have the same number of green cards for employer sponsored immigrants that we had in 1990, over 30 years ago, we're using the same cap on employer sponsored immigrants, which includes everything from geniuses to physicians, all along the spectrum. There is no way to get into this country and contribute in a meaningful way. The United States has half as many physicians per capita as most developed countries. It's a consequence of our outdated immigration laws, also our licensure laws at the state level. Jeff can speak more to that.

I think the healthcare workforce issues on immigration should be something that every American cares about. It should be easy for Congress to address. If you look at it, it's not just physicians, it's also nurses that we have a need for. We have no work visa that enables nurses to enter right away. They're not eligible for the H1B visa. They are only eligible if they get a green card right away, which is a great disincentive for employers to sponsor people, because that process is so costly and the nurse can leave immediately after they've been hired. Some hospitals, they still do it. They'll go through that process, even though they know the nurse can leave them right away. But it's a big disincentive to getting people into the country when you have that kind of process.

Healthcare physicians all the way down to home health aides, a desperate need. We're an aging population, we need to get that done. At the border, unfortunately, we were not anywhere close to a consensus about how to handle that, but we need to work out a deal at least with Mexico on some guest workers who can come in and work in some of these open positions in the United States without having to cross the border illegally. The situation is untenable. We can't keep filling jobs in this country by letting people cross the Rio Grande and have a thousand die every year.

Bob Zadek: And what you just proposed as a course, a starting point, what I found in your solution doctors, nurses, guest workers is there are no victims of that policy. There is no group who will feel threatened by that type of proposal. So, to hope for widespread immigration reform, it's unattainable. But taking the shots one at a time and just going for, as I said, the low hanging fruit, it's so easy to obtain. And once you do, we get used to incrementally a more enlightened immigration policy.

I'll close by pointing out to our listeners that I use the phrase, we all use the phrase immigration reform. Rhetorical question. Did you ever notice that whenever we use the word "reform in public policy," what we are reforming is another policy? It's a bad policy that creates the reform business. How about not messing up to begin with and then there's less to reform?

That's for another show, another day. Thank you so much, David Bier and Dr. Jeff Singer, for sharing with us your thoughts on fentanyl and its relationship, if any, to the open borders, if they are in fact open, which they probably are not. They're just chaotic and most of equal importance. Thanks so much to your wonderful colleagues at the Cato Institute for all of the wonderful work they do. Every time I read a blog or open up a publication from Cato, I can't help but feel smarter and more informed. So, thank you so much, my friends, and thank you to Cato, and thank you to my listeners to giving us that hour of your valuable time. I hope you have found it worthwhile. Thanks so much.