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This line of thinking is tempting as well, that it's just product uncertainty. There may be some factor, but I'm skeptical that it would be the overwhelming factor that a lot of people think. One could easily talk about two movies from this image. In one movie, fentanyl is primarily about product uncertainty, and that has driven a rise in deaths. In another movie, fentanyl is just way more potent and way more dangerous in general, so of course it's going to be higher. But hell, there are still quite a few prescription opioid deaths there; those are chugging along, even though they don't have the same product uncertainty problem. Instead, they mostly fit into the ordering just fine in terms of inherent danger of the substance, regardless of product uncertainty.
Even alcohol is still chugging along, causing deaths, even though there's basically no product uncertainty there. People still try to cram as much as they can into their bodies, just to see if they can and to see if it feels "super awesome, yo". They still party and try different shit, not actually paying all that much attention to what someone is pouring for them or what pill was handed to them. Certainly not carefully looking up the risk statistics of mixing substances and consulting a dosing chart or whatever. Nah, it's, "GET DAT SHIT IN ME AND LET'S GET SUPER HIGH!"
Maybe I'll try putting it this way... the belief that it's just about product uncertainty smells to me a lot like one of Rob Henderson's luxury beliefs. Sure, you may be a rich upper class person who can manage to make casual cocaine holiday work in your life, so long as there isn't product uncertainty in your cocaine, but for many many other people, life just isn't like that. Intense addiction, the need to try always-increasing quantities, and frankly low intelligence/conscientiousness is just going to lead to deaths mostly in proportion to how inherently dangerous the substances are. Product uncertainty can play a role, but a more minor one.
Finally, even if acute ODs do go down a little, what is the cost in terms of long-term mortality? During alcohol prohibition, the government was literally poisoning alcohol, and yet the health benefits in terms of long-term mortality and such were much more significant than the acute effects of their literal, intentional poisoning.
Overdose deaths will certainly keep "chugging along" even without product uncertainty (or inconsistency). Some number will be suicides, some will be chasing a greater high that tolerance has taken away. But I think the best explanation for the increase in deaths is the uncertainty/inconsistency. (I distinguish the two because an inconsistent but known product could be safe in theory, but as you say addicts aren't going to do the math).
As far as I know though, except simply in absolute amount of substance, fentanyl isn't more dangerous than heroin. Fentanyl's therapeutic index -- its ratio of lethal dose to effective dose -- is 400 compared to morphine's 70. I haven't been able to find heroin's TI (it's not prescribed in the US; I would expect UK data but perhaps they use a different term), but it's likely closer to morphine's. It's possible the euphoric dose is (relative to fatal dose) much higher than that of heroin, or that it has a larger tolerance effect, but I know of no evidence for etiher those conjectures. Instead, it seems it's just that the small absolute amounts of the substance are much harder (for both technical and non-technical reasons) for the illegal pharmaceuticals industry to control. The legitimate pharmaceuticals industry has no such problem; it can produce consistent doses even with the far more potent (100x stronger than fentanyl) carfentanil, though there's worker safety problems there.
I think we agree here, but disagree on how inherently dangerous the substances are. Note that "the need to try always-increasing quantities" is part of the inherent danger; some drugs cause more tolerance than others, and sometimes the (acute) lethal dose changes with tolerance.
I think TI alone isn't the right metric to look at. Wiki would put cocaine and alcohol as similar (15 and 10, respectively), even worse than morphine. Rather than it being only a manufacturing concern, I think there's a significant consumability concern, probably with factors of tolerance/euphoric dose/need-to-try-more as you mention, as well as the culture around consumption. Like, you still have to try pretty darn hard to physically consume enough alcohol before your body starts rejecting it (or build up enough of a tolerance). "I'm already drunk as hell, but I want to push to even higher levels.... oops, now I'm asleep," seems to be somewhat of a limiting factor. "I'm already high as hell, but can you imagine popping one or two more before dozing off?" ...takes about five seconds. And that doesn't even account for mixing drugs. Been drinking half the night, just took a hit of whatever, now you're not thinking straight, just thinking about how desperately your body wants to get suuuuuper high right now. You're probably not going to be rationally counting out your pills or whatever according to a dosing chart (for values of "you" that include far less intelligent/conscientious classes of people than you, particularly).
Alcohol is safer (at least in the short term) for various reasons, like the dose one can survive goes up with tolerance, and the difficulty of getting a fatal dose into you without working at it (though college students regularly manage). But I don't think those kinds of differences exist between the commonly-abused opioids. I'm not saying fentanyl would be as safe as alcohol if the dose was controlled, I'm saying it would probably be at least as safe as heroin. And that the massive increase in OD deaths that coincides with the introduction of fentanyl is primarily due to the inconsistency, not the inherent danger.
Also in the alcohol case, I suspect if instead of the common packaging for serious abusers being bum wine or some sort of standard-proof cheap liquor (which are easily distinguishable from each other), it was whatever the addict could get ranging between 5% and 90% alcohol, plus perhaps some isopropyl alcohol mixed in, and the addict couldn't immediately tell the difference by the taste/burn, we'd have a lot more overdoses.
I maintain that "I can imagine a product being adulterated by bad things" is not sufficient reasoning for population rates. One data point that would have to be explained in the chart I linked is the prevalence of prescription opioid deaths. Why aren't other illegal substances, which are presumably adulterated with rat poison, also off the charts in comparison?
My point isn't about adulteration with "bad things", my point was about uncertainty of dosage. I mentioned isopropyl alcohol because it might be considered analogous to fentanyl; it's a stronger alcohol than ethanol in some ways but not toxic in the way methanol is.
Really, the bigger problem for my theory of uncertainty of dosage caused by the introduction of illicit fentanyl into the recreational opiate trade being the main reason for the increase in overdose deaths is the fact that cocaine and meth went up (though not as much) at the same time. As far as I know nothing changed pharmacologically there, so your "inherent danger" theory can't explain it either.
Fentanyl is a colourless white powder and sometimes used to cut cocaine and meth by unscrupulous dealers. Terrible idea, but it will make people feel more fucked up... not to mention make a nice contribution to overdose death statistics.
Interesting, but it unfortunately doesn't distinguish between "inherent danger" and "uncertainty of dosage".
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Most definitely agreed. And now with xylazine, you've got straight methanol or rat poison or something in 1/a few hundred or so? of these bottles of "booze".
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