New York: There's a new major player in America's battle against opioids.
China has been named as an important ally of US efforts to deal with the crippling crisis, as the White House's top drug official warned that fentanyl, a type of synthetic heroin used in strong pain medication and anaesthesia, is at risk of becoming a major global threat.
The US is "facing the worst epidemic in American history", Richard Baum, acting director of the Office of National Drug Control Policy, the principal adviser to US President Donald Trump on drug control issues, told Fairfax Media in an interview in New York.
China has been identified as a producer of illegal fentanyl, he said, adding that US and Chinese governments are cooperating to ban the manufacture and sale of the drug.
"China has asked us to provide information about Chinese-sourced drugs or chemicals so that they can take action and ban them.
"We're trading information about what's happening. We have a DEA office in Beijing and opening up a second office in southern China."
Trump declared the opioid crisis a public health emergency in October. He said it was killing 100 Americans every day. The move is intended to trigger a stronger federal response, allowing expanded access to telemedicine treatment and giving states more freedom to use federal funds to deal with the problem.
Most-recent US government figures estimate 64,000 Americans died in 2016 from using illicit fentanyl, heroin, and prescription drug medications.
The epidemic includes overdoses from prescription opioid medications used as painkillers such as OxyContin and Vicodin. Fentanyl was used for surgery in the 1960s but began being prescribed for chronic pain in the 1990s. The 2016 death of singer Prince, who was battling chronic pain, was attributed to an overdose of non-prescribed fentanyl.
Government statistics suggest 80 per cent of Americans who have used heroin initially misused prescription opioids first. Black market fentanyl is not always sourced from pharmaceutical companies but produced illicitly. Most heroin in the US is produced in Colombia and shipped to Mexico where fentanyl - often sourced from China - is added.
Heroin sells wholesale in the United States for between $US50,000 to $US60,000 ($63,000-$76,000) a kilogram while an equivalent amount of fentanyl can cost as little as $US2500. Introducing fentanyl to a heroin batch dramatically increases profits but creates a more potent and dangerous drug.
Fentanyl - and close versions of the drug called 'analogs' - can be bought online from China and shipped to the US by mail. Packages are either difficult to detect or can be imported through legal grey areas. There are no clear estimates of how much fentanyl is imported into the US through China.
While China has placed fentanyl on its list of controlled substances, the China National Narcotics Control Commission has disputed a claim by Trump that the "flood of cheap and deadly" fentanyl imported into the US was produced in China.
Drug production can be lucrative for Chinese drug manufacturers and China does not have the problems with abuse on the scale of the US. In October 2016, the Associated Press identified 12 Chinese companies willing to export carfentanil around the world for a few thousand dollars a kilogram, no questions asked. Carfentanil is 100 times more powerful than fentanyl and is legally used as an anesthetic for elephants and other large animals.
A commission official, Yu Haibin, told reporters in Beijing last week that there was little evidence showing China was the source of much of the chemicals used in fentanyl production.
"China doesn't deny that shipments to the US happen, but there isn't the proof to show how much - whether it's 20 per cent or 80 per cent," Yu told AP, adding that US authorities have only sent him information about six shipments from China in the past year.
Yu said the US needed to do more to fight its opioid epidemic, including sharing more data and police intelligence with Chinese counterparts.
In 2016, the US Congress agreed to provide $US1 billion to states to provide increased access to treatment and overdose programs. The second $US500 million of that funding program is due in 2018.
Gary Mandell, CEO of Shatterproof, an addiction treatment advocacy group, says the Federal government could fast track the issue.
"We are in a system in the US with distributed decision making and change takes time," Mandell says.
"But we have something similar to Zika or Ebola spreading across our country. We have evidence of solutions that will reduce the number of parents who will have to bury their child and the federal government should jump in with limited specific actions."
The war on drugs - a phrase Richard Baum scoffs at - emerged in 1971 when then former president Richard Nixon declared drug abuse "public enemy number one". Decades-long policies included mandatory sentences for possession, US military aid and on-the-ground presence in producing countries like Colombia, and public education campaigns such as "Just Say No" during the 1980s.
Baum says the current approach differs from the past - not just because China is now within the nexus - but current policy aims to positively engage users rather than make the problem a law enforcement issue.
"We know a lot more about the science of addiction and treatment and prevention and recovery," Baum says. "We don't look at it as either you do law enforcement or you do public health. We need both tools."
Baum highlights the use of police departments across the country, who are assisting users to get treatment, as examples of the new approach.
"If your only illegal activity is buying drugs or using drugs, most of those people can be diverted into treatment and we're doing that like never before," he says. "We have police departments and sheriff's offices all across the country who are actually opening up their police departments and have that as a route to divert people direct into treatment."
Some advocates, like the Drug Policy Alliance, compare using police as surrogate drug counsellors as similar to using law enforcement "to tackle to a measles outbreak" but Mandell welcomes the shift.
"If there's a fire in someone's home it is not just the fire department that shows up," Mandell says. "The police also come."
Baum, though, warns the policy shift does not signal Trump is soft on law.
"American citizens don't want drug traffickers and drug dealers to be allowed to sell these drugs to our families and their communities
"Any country is going to want these criminals to be dealt with. On the other hand, we want drug users to get the help they need."
He also warns that while the opioid epidemic is proving a major issue for the US, other countries also need to be alert because the threat to their citizens is real.
"There are traffickers and organised criminal groups around the world that are beginning to get into selling fentanyl and people are being affected," he says.
"My message is to really keep an eye on this problem and try and shut down these fentanyl production and fentanyl-trafficking rings. If you follow organised crime, they do go where the money is, and this is a lucrative product."