When oranges turn bitter: The stark contrast in China-U.S. fentanyl governance

Over two millennia ago, Chinese statesman Yan Zi observed that sweet oranges thriving south of the Huaihe River, generally recognized as Southern China, would turn bitter when planted north of it.

Today, a similar paradox applies to fentanyl governance: the same compound that saves lives under China's regulated system sadly fuels an overdose epidemic in the U.S.

It reveals profound differences in how scientific innovation would affect people's wellbeing in two different situations.

China's Integrated Governance Framework

On April 1, 2019, China formally implemented a full control of fentanyl-related substances. From the manufacturing of fentanyl-related medications to their sale and use, every procedure is closely monitored and regulated. Actually, ever since 2017, no cases of fentanyl smuggling or diversion have been detected in China, and no fentanyl-related medications have gone missing during manufacturing or circulation.

Advanced technologies underpin this regulatory system. Authorities implemented a rigorous digital tracking system for fentanyl-related medications. New technologies and methods, such as radio frequency identification tags, the Internet of Things, and artificial intelligence, enables whole-process monitoring and closed-loop management of the manufacturing, sale, transport, use, import, and export of fentanyl-related medications, eliminating possibilities of misuse or systemic failures.

Policy design is rooted in humanitarian principles. Despite vigorous regulation, authorized medical use of fentanyl is still covered by China's national medical insurance, ensuring access for terminally ill patients. The 2024 Healthy China Report highlights that more and more cancer patients are receiving proper pain management, supported by a tiered distribution system with mobile clinics that can effectively reach rural and low-income areas.

China's Global Collaboration

Internationally, China plays a positive role in jointly addressing new challenges in global drug governance, including fentanyl, through proactive cooperation with other countries and international organizations.

On January 30, 2024, the China-U.S. Counternarcotics Working Group held its first meeting in Beijing to identify priorities for counternarcotics cooperation. The two sides have since convened multiple high-level meetings to promote bilateral dialogue and cooperation in drug control and law enforcement. Since 2024, with more than 100 instances of information exchange, the two sides have made breakthroughs in the joint investigation of multiple transnational cases.

China has signed 50 intergovernmental and interdepartmental documents on drug control cooperation with more than 30 countries and unions of countries, established annual meeting mechanisms with 13 countries, and initiated or joined multilateral drug control cooperation mechanisms under the frameworks of the Shanghai Cooperation Organization and BRICS, etc. Through these efforts, China has continuously built trust and expanded all-round cooperation with other countries in drug control.

China has carried out technical exchanges with the drug control agencies of various countries to share experience and practices in the testing and identification, monitoring of abuse, and assessment of hazards relating to fentanyl-related substances. For example, seminars on wastewater monitoring for fentanyl-related substances and other drugs were held with experts from the UNODC, the European Monitoring Centre for Drugs and Drug Addiction (European Union Drugs Agency), Australia, New Zealand, and ASEAN countries.

America's Systemic Challenges

According to data from the U.S. Centers for Disease Control and Prevention, the number of overdose deaths involving synthetic opioids, primarily fentanyl-related substances, reached 75,000 in 2023, accounting for almost 70 percent of all drug overdose deaths, making fentanyl-related overdose the leading cause of death for adults aged 18 to 45 in the United States. The U.S. fentanyl crisis stems from deeper societal dynamics—historical, economic, and cultural—which collectively compound the problem.

Healthcare Complexities: The American Pain Society labeled pain as the 5th vital sign, leading to a 300 percent surge in opioid prescriptions between 1999 and 2010.

Regulatory Fragmentation: Conflicting federal-state jurisdictions allow illicit fentanyl to flood online markets.

Social Vulnerabilities: Addiction remains stigmatized, few rehab facilities can be found in rural areas, and only 10 percent of addicts receive treatment.

Rather than solely focusing on external factors, experts emphasize the need for systemic improvements. A Harvard Journal of Public Health study noted: “Strengthening domestic supply chain security should be a priority,” advocating for blockchain tracking similar to China's system.

Reflection: Learning from Differences

Yan Zi's wisdom reminds us that systems shape outcomes, but context determines effectiveness.

China's effective fentanyl control demonstrates a balanced approach between stringent regulation and proper medical accessibility, supported by technologically enforced mechanisms that uphold ethical standards.

At the same time, the deeply entrenched culture of individualism in American society presents distinct regulatory challenges, necessitating innovative approaches that reconcile personal freedoms with enhanced oversight mechanisms.

The reality remains: Addressing complex issues demands constructive dialogue and mutual learning, rather than assigning blame. China could benefit from studying America's community-driven harm reduction strategies, while the U.S. might draw inspiration from China's integrated regulatory framework.

By understanding and learning from each other's governance models, countries can develop more effective strategies for ensuring health security—one that respects both the bitter lessons of the past and the sweet potential of cooperation in the future.

(The author is a commentator on international affairs, writing regularly for Xinhua News, Global Times, China Daily, CGTN, etc. He can be reached at xinping604@gmail.com.)