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Host: Okay. Hello everyone. We welcome you to this technical consultation hosted by Agora in collaboration with the International Network for People Who Use Drugs and Students for Sensible Drug Policy. Our work is centered in policy innovations that promote social justice and sustainable development. Today we're addressing one of the most pressing challenges in the current situation in the US and in many countries, mainly in the West, I would say, which is the transition from botanical production and stability to a toxic synthetic drug supply. Let me put it that way. And we have two specialists today, experts in the topic: Dr. Ben, who will ground us in the long-term history of the opiate crisis—I'm not going to read his whole biography, he can introduce himself too—and Dr. Jade Boyd from the British Columbia Center on Substance Use. She will be sharing evidence on how communities are currently managing risk through route switching, specifically focusing on the use of heroin in this case. Right. Okay. Ben, do you want to begin?

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Dr. Ben: Sure. Yeah. Thank you so much for that really nice introduction. I always feel very daunted and humbled when I'm around practitioners because I'm a historian and so I'm very good at looking backwards and I'm less capable at both reading the present moment and thinking ahead. So it's really nice when I'm able to do that. Think of this as framing. You know, I'm ill-equipped to talk about clinical questions or issues of pharmacokinetics or to think about regulatory pathways, but I do think I can offer a little bit of context on some of the questions that your work brings up. Much of this is drawn—I'm a historian of global economics of commodities—and a lot of this is drawn from my book that's out very soon, in a week or two, which you see here: Markets of Pain: Opium Capitalism and the Global History of Painkillers.

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And I'm hoping that I can draw in just a couple of—maybe offer a periodization, since that's what historians do very well—to try to deepen and complicate some of the really important clinical and policy-facing work that we're going to put on the table today. So, you know, to start with just a very simple and maybe trite observation: when we talk about opium gum, it's easy to lose sight of the fact that this was for most of the 19th and 20th century really the foundation of the global pharmaceutical economy. This material, an agricultural material, when you look from the early 19th century onward, opium is the single most important substance in the Western apothecary. It's the first-line treatment, of course, for pain, but also many other conditions: cough, diarrhea, insomnia; used for basically everything.

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In the United States throughout the 19th century, and really actually beginning in the late 18th, physicians and druggists dispensed hundreds of thousands of pounds of it every year. Most of that in the United States came from the Ottoman Empire, from Turkey, Anatolia. And in the countries that produced that opium—and mostly we're talking here about India and Turkey—hundreds of thousands of farming families sustained their livelihoods by scoring poppy capsules and scraping dried gum, which is a process that you can see in many parts of the world. I've seen it in India and Turkey, but of course, Central America and South America, you can see this in many different contexts, too—Mexico and Colombia primarily.

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So the story of how we got from this world to the world of synthetic opioids—mostly fentanyl, mass overdose death, and a drug supply that is so toxic that it requires adaptation for survival—I don't want us to read as the kind of story from a crude plant to a refined chemical and then synthetic substitutes, even though there is truth to that story. I like looking at the political choices that are made, the imperial and then post-colonial conversations around pharmaceuticals, and then the commercial imperatives that at each stage, I think, narrowed the range of substances and the modes of consumption available for people in pain. And so that story I think of as having three chapters that I want to put on the table for our conversation today. So the first, and this brings us/locates us in the 19th century but takes us to the middle of the 20th, is the chapter of technical isolation and substitution.

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Beginning with the isolation of morphine in 1817 and then accelerating throughout the 19th century, chemists broke down opium into its constituent alkaloids and then began modifying those alkaloids in different ways to create new compounds, and we know these compounds: heroin, synthesized in 1874 and then marketed by Bayer as the first semi-synthetic opioid, and then by the inter-war years, there's a parade of further synthetics and semi-synthetics that followed. So we have oxymorphone, oxycodone, hydrocodone. Each one promises to be more effective and less addictive than its predecessor, and every one of those generally succeeded on the former and failed on the latter account. Maybe a high-water moment that we can put out here is 1959.

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By 1959 we have this synthesis of fentanyl, which is billed as 100 times more potent than morphine. And the dream in all of this—which is stated explicitly by American policymakers on international forums like this one from the 1920s to the 1970s—is to produce a fully synthetic substitute with the aim of severing the world's dependence on the poppy altogether. This is Herman Metz, who you see on the slide here, who in the 1920s dangled out one of the biggest industrial prizes at the time, which was $100,000—so around $2 million at the time—to the first chemist who could synthesize a fully synthetic poppy equivalent. And no one collected on that promise.

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So the second chapter that I want to move us through is this dismantling of a global agricultural infrastructure that worked very imperfectly and with, I think, great human cost in the 20th century to stabilize the illicit pharmaceutical opioid trade. That "worked"—and I put "worked" in scare quotes here—but that functioned from the post-war years to the 1970s. And by the 1970s, though, American policymakers, who were emboldened by the early promise of synthetics, pressured Turkey—though look to India as well—to ban poppy cultivation; pushed India to convert from a very labor-intensive scraping of gum to mechanized poppy straw processing, which it never quite fully did. And so then new production centers beginning in the 80s and then really picking up in the 90s in Tasmania captured more of the world market.

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And so the peasant cultivators who had once been really central to a global pharmaceutical supply increasingly became irrelevant, or proffered their worst to other markets, even as the compounds derived from the plants that they produced remained medically indispensable. So first in Turkey and then in India, the state-run systems that had at their peaks licensed hundreds of thousands of farming families contracted really dramatically. The illicit infrastructure that had maintained some relationship between agricultural labor and state oversight and pharmaceutical production really fell apart beginning in the 80s and the 90s, very slowly and unevenly, and then with consequences that I think are only now becoming visible and tied very much to end-user impacts as well. Instead, I think the third chapter is one that we're living through.

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The infrastructure that once stabilized that global trade in licensed opium collapsed right at the moment when demand for opioids was surging in the late 20th century, driven in large measure by the aggressive marketing of synthetic opioids. And we know this story. When that legal supply was tightened, users turned to heroin. When heroin became adulterated and displaced by fentanyl, the result was the toxic drug supply that this panel has worked on and worked to confound. And I think this was somewhat less aberrant than is sometimes known or realized. I think it was really the wreckage of a global system of production that had governed the world's relationship to pain and its management for well over a century.

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So to connect that arc and these kind of three movements to the whole plant approach that I've seen come up in this panel, I want to be both kind of supportive as a historian and also cautious. I think there's something very correct in observing that the progressive isolation of alkaloids and the drive towards synthetic substitutes has moved the world further and further away from the plant itself and that that movement has had very severe consequences for end users. And I think folks are right to say that this history is shaped by very particular interests. That's imperial science, United States diplomatic pressure, the commercial imperatives of pharmaceutical companies that stood to profit from patentable synthetics rather than an agricultural commodity that essentially anyone can grow.

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I would also complicate that, though, by saying that the category of medicinal opium, which some of your work brings up and has been enshrined in the 1961 Single Convention, was also the product of about a century of political negotiation and wasn't a neutral scientific designation. In 19th-century India, the British had this phrase "quasi-medical use" that described the millions of Indians who used excise opium for an all-purpose household remedy for pain, for calming infants. Opium was incorporated into Ayurveda and Muslim Unani healing—and these are practices that refuse really neat categorization as either traditional or modern. When you look back on materials from the late 19th century like the Royal Commission on Opium, you get a lot of fierce argument about what this particular role of medical/para-medical use is here, too. And I think that none of these debates were really resolved thinly.

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They were resolved by political compromise. And we can point to many other uses. I'm thinking mostly across Asia Major and Asia Minor, where a broad range of uses are winnowed down into something that I think is quite a bit less dynamic. So I don't want to discredit the invocation of traditional knowledge in our discussion today, but I also want to historicize it and to think that we can be a little more careful and not less curious about how we deploy that category in our contemporary policy conversation. And so finally, I also want to notice that the structural position of cultivators, which you've talked about with your colleague in the Mexican context, this is a very old story, too. Indian peasants in the 19th century scraped gum by hand. They delivered it to a state bureaucracy that paid them too little, even as that gum was transformed into the morphine and codeine that stocked pharmacies throughout the world.

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Turkish cultivators sustained a trade that enriched brokers and importers even as they remained bound in cycles of debt. The Mexican poppy farmers described in the safe supply literature, squeezed between criminal organization prohibition and prohibitionist enforcement, watching the price of their crops collapse—they occupy a structural position that I think is really familiar for historians at least. And I think what's new in this work is the insistence that producers be included not just as subjects of prohibition but also potential participants in some form of regulated future here. So, you know, historians are never very good at offering blueprints.

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But I do think that we are good at problematizing some of the categories that we've inherited. And I think of those as medicinal versus non-medicinal, traditional versus modern, botanical versus synthetic. And I think they're not quite stable enough to build policy on without some kind of interrogation. So, I think there are really strong reasons for us to reopen some of the definitions that we're using and we can do that with a very strong awareness of the history that produced them. So, I'm going to leave it there and turn it over to folks who are practicing and in this conversation in different ways and seed the rest of my time with thanks.

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Host: Excellent. Thank you very much for your contribution. I already have a few questions, but I wanted to allow Dr. Boyd to continue with her presentation and then we can think of a Q&A.

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Dr. Jade Boyd: Okay, let me try to share my screen. Thanks so much for having me today. And I was asked to speak on some of my work and some of my colleagues' work doing qualitative research in Vancouver, British Columbia, Canada, documenting some of the recent trends in transitions from injecting to smoking unregulated drugs, primarily opioids, and their health impacts. My work in particular focuses on community-based research, community-focused policy, and kind of the value of centering the expertise of people with the living experience of substance use. Basically to help us better create innovative harm reduction health policy in practice.

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And some of the research I'm talking about today I was hoping to present with my colleague Matt Bonn from the Canadian Association of People Who Use Drugs, but he couldn't be here today. I would say one of the benefits of working collaboratively with community members is that often their innovation for supporting one another in relation to addressing health harms moves a lot faster than policy institutions and also research evaluations.

So in 2016, a public health emergency was declared in Vancouver, BC, because of rapidly increasing overdose deaths primarily from opioids adulterated with fentanyl and its analogues. And we didn't have a lot of harm reduction supports at that time even though we do live in a setting with one of the most comprehensive combinations of harm reduction practices happening in Canada. 10 years ago when the public health emergency was declared in Vancouver, BC, the drug-using community was already working really quickly to support one another and illegally erected a smoking tent and some injection sites. Later, it did become supported by the local health authority, but this tent actually doesn't exist any longer in our setting.

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As I mentioned, we're experiencing a pretty intense drug crisis in Canada and also in the United States. In Canada, we've had over 50,000 deaths overdose-related since the public health emergency 10 years ago. The deaths continue to rise—a little bit lower in 2025, but still increasing—and really it's the leading cause of death in British Columbia between ages 19 to 59. It's primarily driven by illicit fentanyl, but we're seeing from drug checking that they have a lot of different adulterants now in the drug supply like benzodiazepines and tranquilizers that are causing quick and heavy sedation that is also increasing the risk of overdose and also gender-based violence as well. And I'll say it's not only driven by fentanyl, but of course prohibitionist drug policies which create the conditions for unregulated markets and the impetus for higher drug potency.

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Since 2016, there has been a very notable shift in the route of consumption for substances. Many people initially were injection drug users and now we have a higher number of people smoking unregulated opioids. It's basically the mode of consumption in fatal unregulated overdoses right now in British Columbia. You can see the stat there that we had 65% of overdose deaths in 2025 were related to smoking, whereas only 9% were related to injecting opioids. And 69% of people tested in relation to toxicity had fentanyl within the drugs and also other things like cocaine, methamphetamine, etc. In British Columbia, we have more benzodiazepines right now along with fentanyl in the drug supply.

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We specifically spoke to people who smoked instead of injecting. We don't know all the complex reasons why people might shift, but there's obviously some themes. One of the major reasons is to address overdose risk. Many people felt like smoking meant the drugs hit your body a bit slower, so they could deal with such high potency by taking a smaller hit and then waiting to see how it was. Other people felt like they had increased control by smoking; they were able to use smaller amounts than what they might use when injecting. Most people talked about switching to smoking because of safety risks, even though many also acknowledge that people are also overdosing from smoking drugs as well. Half of the participants in our mixed-gender study had overdosed themselves from smoking.

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When people did overdose from smoking drugs, one reason was because the drug supply is highly potent. There's also a rise in poly-substance use, which has resulted in confusion—thinking you're buying fentanyl when actually it's crack cocaine and vice versa. There is also cross-contamination in the drug supply, for example, intentionally consuming opioids while intending to smoke stimulants, or via pipe sharing.

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Of course, there's other reasons for the transition: vein damage is less of a risk when smoking; it can reduce the risk of bloodborne or skin infections. Women expressed a couple of additional reasons: one is a response to addressing overdose risk but also as a response to addressing gender-based violence, particularly sexual assault. Smoking was seen as more protective in that you might be less likely to lose consciousness if benzodiazepines or tranquilizers were in the opioids. Because right now in BC benzodiazepines are so much in the drug supply, we are seeing a lot of rapid blackouts and a lot of sexual assault that is not reported in the way that overdose deaths are. It's a kind of silent violence. For other women, it allowed for further autonomy; women are more likely to require assistance injecting, and with smoking, they didn't need to go out and get that assistance from someone who may expect something in exchange. There were also ideas around gendered beauty and body expectations—smoking is less visible on the body; it's not going to leave track marks.

Obviously, if we had all the answers, we would be dealing with a toxic drug crisis. But there's some straightforward things that could be supportive: expanding sanctioned spaces for poly-substance use and drug smoking, which we really don't have a lot of; expanding advanced drug checking technologies; widespread distribution of smoking-related harm reduction supplies (heat and shatter-resistant glass pipes, foils, etc.); and access to smokable prescribed alternatives to the unpredictable drug supply. We don't really have many smokable pharmaceutical-grade alternatives in BC right now, meaning a lot of people who are at high overdose risk are not having their needs met.

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Host: I've been volunteering in a safe consumption site here in New York called On Point. A question that I would like to ask specifically for Benjamin: if we want to focus on users of opium gum, then we would have to consider outdoor places where users can use responsibly. Although it's also possible to implement strategies that would allow consumers to use indoors without putting at risk others, for example, by vaping. How can we transition from the raw opium gum that is smoked through pipes to a modern version that would fulfill the needs of the user and at the same time it won't disturb anyone around? Because that's the thing when we smoke indoors—that we're bothering the rest.

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Dr. Ben: What an interesting question. When I'm thinking about traditional consumption, I'm thinking of practices that are fundamentally social ones. The shift from smoking to injection is a really deleterious one. I'm curious, Jade, what those sites might look like that accounted for the different ways in which people use both for the somatic effect, but also the social function that they play. This is a very live debate where I am in Boston, too.

Sylvia: I've been a street worker for many many years and I'm a psychotherapist now. We don't have consumption rooms in Vienna. It's terribly conservative because they're always afraid of the right-wing parties. But there is one example in Hamburg—it's a female-only consumption room. A lot of sex workers use this and I was thinking that sometimes it's easier to establish something for "vulnerable folks" that nobody is really afraid of. Political this is a highly political thing, but we have to look at how they do it in other places. In general, this shift to do it for women causes less aversion from some parties. It's really important to get the women into these sites.

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Host: How can we convince the smoking rooms for cannabis to allow other types of drugs because they already have the expertise?

Dr. Jade Boyd: Cannabis is legalized in Canada, so it's not really much of a big deal here. In Vancouver, we do have an indoor overdose prevention site that allows for smoking—it's sort of like a different room with safety regulations and vents. But we've also just switched in British Columbia; we had a decriminalization project going on, but there's a lot of backlash from the conservative government. They were so concerned about people smoking in public that now we've gotten rid of decriminalization. We've also switched to "forced witnessing"—people accessing alternatives now have to be witnessed by a pharmacist or a doctor.

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I just add that I've been to On Point in New York and it is so much nicer than anything we have in British Columbia. It was really wonderful to see how it addresses so much more than substance use—housing, social services, food, safe sex supplies.

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Dr. Ben: I'm curious about the changing political contexts here. There is at once a conversation in American cities about "disorder" and the optics of public use. One would think that would translate into greater support for supervised consumption spaces, but it doesn't seem like it's translated that readily into a policy push.

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Host: Is the adulteration issue a modern challenge?

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Dr. Ben: Historically, anyone who had access to opium gum was always worried about it being adulterated with wax or coal or a million different things. I think the difference is probably the toxicity. That was a question about purity and efficacy versus the question of fatality we see today.

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Sylvia: In Austria, everything has been cut down a third. The only space where things are still expanding is the university clinic of psychiatry. I have projects there with ketamine and psilocybin. For example, laughing gas is extremely effective—I can only recommend it. There are a lot of studies going on in Europe and the US. I think this is something we have to rely on because the communities don't have the money anymore. It needs to be funded, and it's not possible to expand low-threshold stuff at the time being.

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Dr. Jade Boyd: I'd say absolutely. In Vancouver, the overdose deaths are really tied to broader social structural factors like poverty and lack of housing. Now we can see very much that synthetic and semi-synthetic drugs which are adulterated in our supply still aren't necessarily working either.

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Host: Where can I find the video recording?

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Host: It's going to be on the Agora Lab website.

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Sylvia: I'm representing the association of Austrian professionals in the field of drugs.

Host: And your organization, Agora Lab, what is it?

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Host: We have been implementing initiatives to promote public policies. We're trying to convince decision makers about the impact of regulating and decriminalizing drugs. The organization was born in Mexico and we now have representation in different countries.

 

Sylvia: In Vienna, we have a hydromorphone project—it's all scientific. Without science, nothing is working here anymore.

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Host: I've been working with an organization based in Colorado called Psychedelic Science.

 

Sylvia: This is a topic I'm really interested in. I think they have a great potential for healing.

 

Host: Do you know the book by Michael Pollan, How to Change Your Mind?

 

Sylvia: Yes, I love it. All these programs running at the university clinic in Vienna and Berlin—the money comes from funding. It's about non-treatable depression, and they expanded it to people who are bipolar because they have a high suicidal risk. And ketamine is anti-suicidal. In Austria, it's allowed in the university clinic for research. Luchi Bartova established it and now it is even paid by social security. They also do it for PTSD. I hope they expand it more in terms of substances and not only stick with ketamine or psilocin. For example, kratom is another alternative for depression.

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Host: I think the only country in the world that has allowed psilocybin is Australia.

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Sylvia: And MDMA, too. This is the way to start stuff—in research. It takes terribly long, a lifetime is not enough, although we'll keep trying until it happens.

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Deep Analysis

The technical consultation highlights a critical historical and sociological turning point: the transition from a stable, botanical-based drug economy to a volatile and toxic synthetic supply.

1. The Historical Narrative of "Isolation"

Dr. Ben’s analysis reframes the current fentanyl crisis not as a natural progression of science, but as the result of political and commercial imperatives.

• The Three Chapters: The shift began with the technical isolation of morphine (1817) and heroin (1874), followed by the deliberate dismantling of global agricultural infrastructures in Turkey and India during the 1970s. This severed the link between traditional farming families and state-regulated pharmaceutical production.

• The Synthetic Dream: The goal of Western policymakers was to produce a fully synthetic substitute to end dependence on the poppy plant. This resulted in the synthesis of fentanyl (1959), a substance 100 times more potent than morphine, which eventually flooded the unregulated market when legal supplies were tightened.

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2. Route Switching as a Risk Mitigation Strategy

Dr. Jade Boyd’s qualitative research in British Columbia reveals that people who use drugs are actively attempting to manage the toxicity of the supply by switching from injection to smoking.

• Safety Perceptions: While smoking is perceived as a way to have more control and "slow down" the onset of highly potent drugs, data shows it is not inherently protective, as smoking-related deaths in BC reached 65% in 2025.

• Protection from Violence: For women, smoking is a survival strategy to avoid the "blackouts" associated with benzodiazepine-adulterated drugs, which leave them vulnerable to sexual assault.

• Autonomy: Smoking allows for greater independence, particularly for those who might otherwise require assistance with injection, which often involves an exploitative exchange.

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3. The Scientific Framework for Policy Change

 

A recurring theme, particularly from the European perspective shared by Sylvia, is the role of clinical research as a gateway to policy acceptance.

• Research as a Shield: In conservative political climates like Austria, the expansion of services for substances like ketamine, psilocybin, and MDMA is only possible under the guise of university-led research.

• Redefining Categories: Dr. Ben argues that the categories we use—medicinal vs. non-medicinal, traditional vs. modern—are unstable political compromises. To address the current crisis, policy must interrogate these inherited definitions and move toward inclusive, regulated futures that involve the expertise of both producers and users.