One of the most complicated challenges that Pakistan will face in the not-too-distant future is the opioid epidemic, which is not just wreaking havoc in the USA, but is also threatening to break out and become a worldwide epidemic. There is a definite problem in the USA, with 50,000 deaths there in 2016 from overdoses, and a similar number of deaths per capita in Canada. Since 2000, there have been more deaths in the USA due to opioid overdoses than in World Wars I and II combined.

Pakistan would probably ignore this problem, even though it also cost the US economy $504 billion, or 2.8 percent of its GDP that year, because it itself suffers from an opioid problem, that of heroin addiction, but it is so revolutionary, that it will impact its drug scene. The use of cocaine in Pakistan shows the influence of American culture, for it is the upper-end drug of choice for wannabes. However, while heroin is produced from the opium plant, which is grown mostly in nearby Afghanistan, cocaine is produced from the coca plant, grown in Central and northern South America: thus both drugs are plant-based.

The new opioid epidemic should not be confused with the old one. The old one, or rather old ones, started when people who did not need heroin or cocaine medically used them for their euphoric properties. This built on those who had become addicted to them after medical use. Heroin and cocaine are both highly effective painkillers, and even now can be prescribed either as anaesthetics or as painkillers for post-operative patients or the terminally ill. However, whether used medically or recreationally, users develop tolerance, and require ever increasing amounts to achieve the same results. The result can well be a fatal overdose. The memory has still not faded of the 2009 death of musical phenomenon Michael Jackson, because he was using propofol, which is such a strong anaesthetic that it can be used on horses, to help him sleep. He also ingested benzodiazepine, which are a type of tranquillizer sometimes taken by opioid users to enhance its effects, even though the combination increases the lethality.

The present epidemic started because the large pharmaceutical companies have aggressively marketed opioid painkillers. The Gosport Hospital scandal in the UK, in which 456 ‘lives were shortened’ by opioid over-prescription between 1989 and 2000, illustrates how doctors were inured to prescribing the opioids about which they were initially reluctant. Now that there is an increasing attempt to regulate the North American market, Big Pharma is taking a leaf out of the book of Big Tobacco, and moving overseas. An added factor has been the proliferation of the synthetic opioid fentanyl, which is fair set to transform the international drug market beyond recognition.

Another factor that would be hauntingly familiar to Pakistanis is the involvement of a refugee population. Refugee populations are naturally vulnerable to the temptation offered by drug money, and the presence of Afghan refugees in large numbers from the 1980s onwards helped Pakistan become a hub of the heroin trade. Now there are reports that the Rohingya refugees in Bangladesh are acting as carriers for amphetamines, manufactured in Myanmar, and consumed in Bangladesh and India. Though there is no apparent Rohingya involvement in the opioid trade, it is probably only a matter of time before suppliers begin using this convenient tool.

It is significant that the amphetamines are being manufactured in Myanmar. This means that synthetic opioids, fentanyl being the main one, can be manufactured in Myanmar. In fact, it can be manufactured in any country with even a rudimentary chemical industry. Thus, instead of having to import plant-based narcotics like heroin and cocaine, suppliers will be able to manufacture them. One implication is that it will not be necessary to transport them. Those gangs which make their money off transporting drugs will not take their cut. This means that the price of even heroin will be driven down, cutting into both the high profit margins prevailing, as well as the ability of drugs to fund liberation struggles or insurgencies.

Another piece of pricing has to be factored in. Prescription opioids, legally obtainable, can be sold for roughly the same price as heroin, even though heroin is three times as potent. So with the money, users buy heroin, and get thrice the kick, or if they need the money, keep the difference. This creates a cap on heroin prices, for if they rise, it makes more sense to consume other opioids. The USA is relatively protected by the fact that opioids are only available on prescription. However, prescriptions are issued on the basis of what patients, who could be criminals, report about the amount of pain they feel. Pakistan, where drugs are sold over the counter without prescription will be a paradise, with not even this woefully inadequate barrier. This would especially be so with governments willing to give Big Pharma a hearing, just as was given to a foreign tobacco company which managed to persuade the government to have a smaller warning sign on packets.

It is as unlikely that heroin and cocaine will be entirely driven out of the market as it is likely that they will plummet in price. Price will not be the only reason to use them. Cocaine is favoured by Pakistani wannabes with money to burn. As it has to be smuggled into the country, being brought by circuitous routes from Central and South America, it is expensive. However, because it has the imprimatur of the US elite, some use it, and have developed an addiction. For such wannabes, when opioids catch on in the American elite, they will become attractive. If one adds in their cheapness and the local manufacture of synthetic opioids, they will become irresistible.

US government priorities will also change. At present, it does nothing to affect the demand side of the equation, concentrating the bulk of its efforts on cutting the supply. When demand falls, supply will grow less. Same time, the USA’s engagement with a wide range of countries, which includes drug enforcement, where the USA provides aid for it, will change. It is likely that, having chemical industries capable of manufacturing the requisite materials, India and China will be in the forefront of supplying precursor chemicals to the USA. Pakistan too has related experience, in the shape of the 2012 ephedrine scandal which involved then Prime Minister Yousuf Raza Gilani’s son. Ephedrine, legitimately used in cough syrups, is also known as the poor man’s ‘ecstasy’, because its effects resemble those of that synthetic drug.

Both India and China would like to rival the USA, but whether they would like to afford the cost of having large segments of their populations addicted in order to develop a domestic market, is doubtful. However, both are likely to find their populations falling into the trap of addiction to opioids, not just because of wannabes, but in the case of the latter (and of Pakistan) of Diaspora populations which have proved the most efficacious means of spreading Western culture.

Thus there is no use burying our head in the sand, or expecting the interest the USA takes in Pakistan because of heroin, to continue. Addiction is like a tidal wave: it sweeps everything in its path. Pakistan has already undergone a heroin addiction disaster. It is now likely to join the world in a much greater disaster, that created by opioids.

The writer is a veteran journalist and founding member as well as executive editor of The Nation.

maniazi@nation.com.pk