《習、拜握手與“芬太尼”那張牌》（Xi, Biden Handshake and the Fentanyl Card）

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習、拜握手與“芬太尼”那張牌 （Xi, Biden Handshake and the Fentanyl Card）

借著APEC的機會，習近平主席飄洋過海，帶著他的紅旗防彈車，來到舊金山與拜登第二次握手了。上一次握手時拜登是副總統。快80歲了還堅持工作且有promotion，在美國曆史上也是奇跡。

Taking advantage of the APEC opportunity, President Xi Jinping sailed across the ocean, bringing his "Red Flag" armored vehicle to San Francisco to shake hands with Biden for the second time. The last time they shook hands, Biden was the Vice President. Approaching 80 and still holding a job with promotions, he is indeed a “miracle” in American history.

雙邊會談4個多小時，涉及很多大事，比如恢複兩軍高層溝通、台灣問題、烏克蘭問題、哈馬斯問題等等。說實話這些我都不太關心，這些事情該怎樣就怎樣，不是兩人握個手就有什麽改變的。

The bilateral talks lasted for more than four hours, covering many major issues such as restoring high-level military communication, the Taiwan issue, the Ukraine issue, the Hamas issue, and more. To be honest, I'm not very concerned about these matters; they will unfold as they will, and a handshake won't necessarily bring about any changes.

然而在他們的交流中，卻涉及了一樁“小事”，即芬太尼問題。其實這個問題對美國是個大問題，它是目前導致美國中、青年死亡的首要因素，而且愈演愈烈。我希望在這次見麵以後，根據習主席的承諾，在未來的N年，事情能夠好起來。

However, in their exchange, a "small matter" was involved: the fentanyl issue. In fact, this problem is a significant one for the United States. It is currently the leading cause of death among middle-aged and young Americans and is escalating. I hope that after this meeting, according to President Xi's commitment, things can improve in the coming years.

什麽是芬太尼  What is Fentanyl?

芬太尼（Fentanyl）是一種強效的阿片類（opioids）止痛劑，它比嗎啡效力高百倍。芬太尼於1960年代研發出來，很快成為醫學中使用最廣泛的合成阿片類藥物。【注：阿片類（opioids）與鴉片（opium）在含義上是有一些區別的。鴉片是從罌粟果實裏提取的生物堿的混合物，可鎮痛，有成癮性。而阿片是一大類合成或半合成的，具有類似生物活性的化合物，包括芬太尼。Opioids一般比opium效力要強得多。】

Fentanyl is a potent opioid analgesic, about 100 times more powerful than morphine. Developed in the 1960s, it quickly became the most widely used synthetic opioid in medicine. [Note: There is a distinction between opioids and opium. Opium is a mixture of alkaloids extracted from poppy fruit and has analgesic and addictive properties. Opioids encompass a broader category of synthetic or semi-synthetic compounds, including fentanyl, and are generally more potent than opium.]

可能有人會問，不是已經有布諾芬、泰諾、利多卡因等鎮痛劑嗎？為什麽還要使用阿片鎮痛劑呢？主要原因是，雖然布諾芬之類對於頭疼腦熱或一般局部疼痛有不錯的鎮痛效果，但對於因外傷、手術和晚期癌症等導致的劇烈疼痛，這些弱鎮痛劑就不行了，還需要依靠阿片類強鎮痛劑，如嗎啡（Morphine）、杜冷丁（Demerol）、羥考酮（Oxycodone）等，當然也包括芬太尼。簡單而言，芬太尼傳統上是作為強鎮痛劑在臨床上使用的。

Some may wonder, with pain relievers like ibuprofen, acetaminophen, lidocaine, etc., why use opioid analgesics? The main reason is that while drugs like ibuprofen are effective for headaches, fever, or general localized pain, they are not sufficient for severe pain resulting from injuries, surgeries, late-stage cancer, etc. For such intense pain, opioid analgesics like morphine, meperidine (Demerol), oxycodone (OxyContin), and fentanyl are needed. In short, fentanyl is used clinically as a powerful analgesic.

上述這些強鎮痛劑是通過它們在腦的神經細胞上的三種受體，即μ型、δ型和k型受體起作用的。不幸的是，這幾種受體被激動，既是產生強鎮痛的條件，又與產生依賴性有密切的關係，所以這些藥物也都是控製藥物。由於成癮性這個巨大的缺點，發現不帶成癮性的強鎮痛劑就成了藥物研發的一個重要課題。美國國立健康研究院NIH在幾年前也開始了一個PSPP計劃，試圖有所發現，但目前來看困難極大。有些學者甚至認為，將與成癮有關的阿片受體與強鎮痛效果分開是行不通的。

Opioid analgesics act on three receptors in the brain's nerve cells (neurons): μ-type, δ-type, and κ-type receptors. Unfortunately, these receptors, when activated, not only produce strong analgesia but also have a close relationship with the development of dependence. Therefore, these drugs are controlled substances. Due to the significant drawback of addiction, developing non-addictive analgesics has become an important topic in drug research. The National Institutes of Health (NIH) in the United States started a PSPP program a few years ago, attempting to make breakthroughs, but it seems very challenging. Some scholars even believe that separating opioid receptors associated with addiction from the analgesic effect is not feasible.

芬太尼為什麽殺人  Why is Fentanyl Deadly?

癮君子服用各種違禁藥物，但大多數的死亡都是因服用阿片類藥物所致。即使在醫療上作為鎮痛藥，如果使用不當，也會出現過服（overdose），嚴重者會導致死亡。而其他種類的毒品，如可卡因（Cocaine）、冰毒（甲基苯丙胺，Methamphetamine）、氯胺酮（Ketamine）等致死較少，這是為什麽呢？

While drug addicts use various illicit substances, most deaths are caused by opioid use. Even in medical settings as pain relievers, improper use can lead to overdose, with severe cases resulting in death. Other types of drugs, such as cocaine, methamphetamine, ketamine, etc., are less likely to cause death. Why is that?

原來，阿片受體，特別是k受體在下丘腦呼吸中樞廣泛分布。如果過服，就會導致呼吸抑製。特別重要的是，阿片受體都具有很明顯的“耐受”的特性。當反複服用阿片類藥物時，受體的敏感性會下降。這時候，同樣劑量的阿片類藥物就不那麽“有勁”，不能產生相同的鎮痛效果或愉悅感了。 這就叫做藥物耐受性（tolerance）。 阿片類藥物的耐受性驅使使用者增加劑量，這樣他們才能保持鎮痛效果或愉悅感。但如果增加太多，就會因過量導致呼吸衰竭。

Opioid receptors, especially the κ receptors, are widely distributed in the brain's respiratory center in hypothalamus. Overdosing can lead to respiratory failure. Importantly, opioid receptors exhibit clear "tolerance." When opioids are repeatedly used, the receptors become less sensitive. At this point, the same dose of opioids is not as effective, failing to produce the same analgesic or euphoric effects. This phenomenon is known as drug tolerance. The tolerance drives users to increase the dosage to maintain the analgesic or euphoric effects. However, excessive dosage can lead to respiratory failure and, ultimately, death.

另一個特別重要的致死原因是，癮君子因故停服了一段時間（比如因為想戒斷、阿片類藥物斷供了或者沒錢買了），一段時間以後再服。可是他們不懂，在停服以後，受體的敏感性會逐漸恢複。如果他們恢複用藥時使用的劑量，是上次他們停止之前的劑量，那麽，因為受體敏感性已經恢複，該劑量就大大過量了，很可能立刻導致呼吸中樞衰竭而死亡。這就是為什麽阿片類藥物對癮君子非常危險。

Another crucial reason for fatalities is when drug users stop using for a period (e.g., for detox, lack of opioid supply, or lack of funds) and then resume use. They may not be aware that after discontinuation, the sensitivity of the receptors gradually recovers. If they resume using the same dosage as before, the dosage becomes significantly excessive due to the restored receptor sensitivity, potentially causing immediate respiratory failure and death. This is why opioid drugs are particularly dangerous for addicts.

美國最近10年的芬太尼之殤  The Fentanyl Tragedy in the Last 10 Years in the U.S.

美國的毒品（各種類型）的泛濫曆史很長，反映美國社會自身的問題，這個此處不贅述。而美國對於疼痛又有一種“鎮痛文化”。所謂“鎮痛文化”，是說的當病人出現疼痛時，傾向於使用藥物控製，保證基本的生活質量，而不是忍耐。然而，醫源性廣泛使用阿片類藥物鎮痛（特別是長期使用），不免使得少數病人成為癮君子。另外，在本世紀以前，藥廠為了賺錢，有淡化合成類阿片藥物成癮性的問題，FDA的監管曾經也不夠嚴格。但這些問題，大約從本世紀開始有了比較大的改觀，這些年，醫源性藥物濫用，特別是因此導致的死亡並沒有明顯增加。

The history of drug abuse in the United States, across various types, reflects the country's societal issues, which will not be elaborated on here. The U.S. also has a "pain culture" wherein both patients and healthcare providers tend to use medications to control pain, ensuring basic quality of life rather than enduring it. However, the widespread use of opioid analgesics, especially for prolonged periods, has led to a minority of patients becoming addicts. Additionally, until the early 21st century, pharmaceutical companies downplayed the addictive nature of synthetic opioids, and the FDA was not stringent enough in regulating them. However, these issues have seen significant changes in recent years. Although there is still misuse, opioid-related deaths relevant to medical use have not increased significantly.

然而，大約從10年前的2013年開始，過量服用（overdose）阿片類藥物導致的死亡的案例直線上升，2015年超過5萬（超過交通事故或槍殺死亡人數），2017年超過7萬，2020年超過9萬，2022年達到11萬。這些非正常死亡大都數跟醫生開藥鎮痛無關。而且，與新冠不同，這些藥物過服的死亡者，主要是年輕人，很多是美國“鐵鏽帶”中小城鎮的年輕人。這些地方，本是美國產業的重要組成部分。但全球化使得這些地方衰敗、破落，年輕人很多失去了工作，用藥物來填補精神空虛。

However, starting around 10 years ago in 2013, the number of deaths due to the overdose of opioid drugs has been steadily increasing. In 2015, it exceeded 50,000, surpassing the number of deaths from traffic accidents or gun violence. In 2017, it exceeded 70,000, and by 2020, it had surpassed 90,000. In 2022, it reached 110,000. Most of these abnormal deaths are not related to prescribed pain medication. Unlike COVID-19, the victims of overdosing on these drugs are primarily young people, many of whom come from small towns in the "Rust Belt" of the United States. These places were once vital components of the American industry. However, globalization has led to their decline, and many young people in these areas have lost their jobs, resorting to drugs to fill the void in their lives.

下麵這條曲線是減去其他藥物，專門顯示合成類阿片（主要是芬太尼）每年導致的死亡人數，從中可以看到最近10年死亡人數如火箭式上升。這些案例幾乎完全與醫療無關，藥物全部從黑市上獲得。現在，美國每年因芬太尼死亡8萬多鮮活的生命，而且還在加速上升，這是美國的不能承受之重。多年以前，美國就說這是“芬太尼危機”（Fentanyl crisis），一定要盡快解決，可是從圖上看，除了2017-2019這三年稍顯希望外，其他年份的情況令人沮喪。因為芬太尼問題不是美國自己能解決得了的。

The curve below subtracts deaths caused by other drugs and specifically shows the annual number of deaths caused by synthetic opioids, mainly fentanyl. From it, we can observe a skyrocketing trend in the number of deaths over the past decade. These cases are almost entirely unrelated to medical treatment, as the drugs are obtained entirely from the black market. Currently, more than 80,000 lives are lost each year in the United States due to fentanyl, and this number is still rapidly increasing. It has become an unbearable burden for the United States. Many years ago, the U.S. referred to this as the "Fentanyl crisis" and emphasized the need for urgent resolution. However, looking at the graph, apart from a slight improvement in the years 2017-2019, the situation in other years is disheartening. The fentanyl problem is not something the United States can solve on its own.

傷天害理的買賣  The Lawless and Immoral Trade

大量流入美國的芬太尼絕大部分直接或間接來自中國。芬太尼是全人工合成阿片，工藝成熟，原料藥（前體化合物）容易得到，成本很低。而且芬太尼可以口服，不需要像海洛因或嗎啡那樣注射，對“消費者”也方便。而在相當長的一段時間裏，中國沒有針對相關問題的立法。於是，合成芬太尼成了掙錢的行業，很多民營化工廠都做。中國生產的“物美價廉”的芬太尼開始飄洋過海 。比如在2016-2017年，美國執法部門從國際郵件中查獲的芬太尼中，97%來自中國。

The majority of the fentanyl flowing into the United States comes directly or indirectly from China. Fentanyl is a fully synthetic opioid with mature technology, easily obtainable precursor chemicals, and low production costs. Moreover, fentanyl can be taken orally, eliminating the need for injection like heroin or morphine, making it convenient for "consumers." For a considerable period, China had no legislation specifically targeting these drugs. As a result, the production of fentanyl became a lucrative industry, with many private chemical factories involved. China's "affordable" fentanyl products were shipped across the ocean. For example, 97% of fentanyl seized from international mail to the U.S. originated from China in 2016-2017.

在2018年以前，從美國毒販從中國諸多網站直接郵購芬太尼達到令人發指的程度。美國毒販可以在網上輕鬆下單，中國公斤級的芬太尼直接快遞到美國。比如，杭州有一個網站叫“維庫”（Weiku.com），上麵有近百家公司銷售芬太尼。每磅有的才一、兩千美元，如此的白菜價（加上芬太尼的極高藥力），即使流通的每個環節都掙大錢，到“消費者”手上，每劑仍然可以便宜到1美元，這是吸食海洛因、可卡因等不可想象的，所以買不起麥當勞的癮君子也用得起芬太尼。

Before 2018, U.S. drug dealers could heinously order fentanyl directly from numerous Chinese websites. They could effortlessly place orders online, and kilograms of fentanyl from China would be sent directly to the U.S. For instance, there was a website in Hangzhou called "Weiku.com," where nearly a hundred companies once sold fentanyl. Each pound cost only one or two thousand dollars, an incredibly low price (combined with fentanyl's high potency). Even with substantial profits at every stage of circulation, the cost to the "consumer" was still low, around $1 per dose. This affordability made fentanyl accessible even to addicts who couldn't afford fast food.

中美的不平坦的合作  Bumpy Cooperation Between China and the U.S.

在早期，美國便敦促中國查辦非法生產芬太尼的中國企業，中國反應比較冷淡。芬太尼在中國國內沒有濫用的危險，因此中國方麵沒有太多動力進行監管。特朗普剛任美國總統時，兩國有一個比較友好的試探期。期間美國敦促中國在此事上加強力度。於是中國頒布了全麵禁止合成阿片類藥物的新法律，對國內規模龐大、不受監管的芬太尼行業進行了打擊，對美國的死亡人數減少起到了立竿見影的作用。上麵兩個圖中，2017-2019變得平緩就反映了這一點。

Many years ago, the U.S. started to urge China to investigate Chinese companies involved in illegal fentanyl production, but China's response was lukewarm. Fentanyl did not pose a risk of abuse in China, so there was not much motivation on the Chinese side to regulate it. In the early days of Trump's presidency, there was a relatively friendly trial period between the two countries. During this time, the U.S. urged China to intensify efforts on this matter. Consequently, China enacted a new law banning the synthesis of opioid drugs comprehensively, dealing a blow to the unregulated fentanyl industry at home and leading to an immediate reduction in the number of deaths in the U.S. The flattened curves from 2017 to 2019 in the two graphs above reflect this.

然而，中國加大監管的力度像是給美國人情。於是當兩國關係出問題的時候，情況便急轉直下。像上麵那種卓有成效的打擊和雙邊的合作，很快就隨著貿易戰、美國對中國人權的批評，以及台灣問題而擱淺。於是芬太尼的買賣又活躍起來。

However, China's increased regulation seemed like a favor to the U.S.  When the relationship between the two countries soured due to trade wars, U.S. criticism of China's human rights, and disputes over the Taiwan issue, effective cooperation quickly stalled. Consequently, the fentanyl trade became active again.

此時，由於直接製造和銷售芬太尼在中國已屬非法，於是中國不法分子掙黑錢的方式又有所改變，他們開始與墨西哥毒梟合作。2019年以來，在大多數情況下，他們將原料藥走私到墨西哥，在那裏被非法合成後在販運至美國。結果是阿片類（主要是芬太尼）過服導致的死亡再次急劇上升，2022年達到近11萬人（包括少量醫源性）。

Now, since direct manufacturing and export of fentanyl are illegal in China, illegal elements found alternative ways to profit. They began cooperating with Mexican drug cartels. Since 2019, in most cases, they smuggled precursor chemicals to Mexico, where they were illegally synthesized and then trafficked to the U.S. The result has been a sharp increase in deaths due to opioid overdose (mainly fentanyl), reaching nearly 110,000 in 2022, including a small number of medically sourced cases.

2023年夏天的時候，兩國在這個問題上的合作前景極為暗淡。當時布林肯主持了一個84個國家參加的視頻會議，希望多國一同向中國施壓，要求其采取更強有力的措施遏製用於製造芬太尼的原料藥流向他國。隨後，美國聯邦檢察官宣布起訴四家中國企業，指控它們非法販運化學品，經墨西哥販毒集團，製造大量銷往美國的芬太尼，美國的一些議員也強烈譴責中國不負責任。

As of the summer of 2023, the prospects for cooperation between the two countries on this issue are bleak. In July, Secretary of State Blinken chaired a video conference with 84 countries, hoping to pressure China collectively to take stronger measures to curb the flow of precursor chemicals used to manufacture fentanyl to other countries. Subsequently, U.S. federal prosecutors announced the indictment of four Chinese companies, accusing them of illegally trafficking chemicals, which were then used by Mexican drug trafficking groups to manufacture large quantities of fentanyl destined for the U.S. Some U.S. lawmakers also strongly criticized China on this issue, accusing it of irresponsibility.

對此，“中國不吃那一套”。比如7月27日《人民日報》就發表社論說：“在禁毒問題上，美方必須正視自身問題，不能諱疾忌醫。攻擊抹黑中國治不了美國國內毒品泛濫的痼疾。” 一段時間裏，國內媒體猛烈抨擊美國，指責美國將自身社會問題歸咎於中國，弄得國內盡人皆知。在我給國內父母打電話時，他們就問我芬太尼是怎麽回時，為什麽美國人吸毒怪中國。

In response, "China does not buy it." For example, on July 27, the People's Daily published an editorial stating, "On the issue of drug control, the U.S. must face its own problems and not shy away from them. Attacking and smearing China cannot cure the chronic disease of drug abuse in the U.S." For a while, domestic media fiercely countered U.S. accusations, blaming the U.S. for attributing its social problems to China, making it widely known domestically. When I called my parents in China, they asked me about fentanyl and why Americans blame China for drug addiction.

籌碼與回報  Chips and Returns

時間剛過去三個月，兩國的關係出人意料地回暖了。雙方都感到，冷淡與對抗不是最好的選擇。於是習、拜懷著各自的願望又握手了。正可謂“國與國之間沒有永遠的朋友，也沒有永遠的敵人，隻有永遠的利益。”這句話被很多人看得很不堪。其實，照顧利益未必喪失原則，特別是基本的道義原則。在這方麵，我對美國有信心。

Just over the past three months, the relations between the two countries unexpectedly warmed. Both sides felt that coldness and confrontation were not their best interests. So, Xi and Biden shook hands again, each harboring their own wishes. It is indeed true that "nations have no permanent friendship or hostility, only permanent interests." Many find this saying distasteful. However, taking care of interests does not necessarily mean sacrificing basic moral principles. In this regard, I have confidence in the United States.

就芬太尼這件事情來講，生產、出口芬太尼都不是中國政府所為，同時它也沒有把藥往美國人嘴裏喂。而且中國紙麵上的立法已經完成。因此，中國可以說它是很幹淨的。芬太尼問題可以當作一個籌碼。究竟花多大力幫助美國解決芬太尼問題，取決於獲得什麽樣的回報，包括在自己感興趣的領域迫使美國讓步，或者要求美國在一些地方不再給中國共產黨難堪。

Regarding the fentanyl issue, neither the Chinese government advocates the production and export of fentanyl, nor does it force the drug into the mouths of Americans. Moreover, China has completed legislation on paper. Therefore, the Chinese government can claim to be clean. The fentanyl issue can be used by the Chinese government as leverage. How much effort China will put into helping the U.S. solve the fentanyl problem depends on the returns it gets, including compelling the U.S. to make concessions in areas of interest to China or requesting the U.S. not to embarrass the Chinese Communist Party in certain matters.

前天（16日），美國政府將中國公安部物證鑒定中心從商務部貿易製裁名單上移除。該機構於2020年被美國列入貿易製裁名單，因其涉嫌侵害維吾爾族人，中國一直對此相當不滿。與此同時，中國國家禁毒委員會針對可用於製造毒品的物質，對有關行業的生產和銷售發出警告。中國官方同時稱不要拘泥於外國執法機構“長臂管轄”之中。它嘴上總要說，是我主動要做的，不是因為你的原因。

Two days ago (November 16th), the U.S. government removed the Chinese Ministry of Public Security's Forensic Identification Center from the Department of Commerce's trade sanctions list. The institution was listed in 2020 for allegedly violating the rights of the Uighur people, and China has been quite unhappy about it. Simultaneously, the China National Narcotics Control Commission issued a warning to domestic industries related to the production and sale of substances that could be used to manufacture drugs. Chinese officials also stated that they should not be confined to the "long-arm jurisdiction" of foreign law enforcement agencies. The official stance is that China took the initiative and did not act because of external pressure.

有趣的是，拜登繼續稱習近平是“獨裁者”（dictator）。這雖然帶有一點貶義，但也不那麽壞，就是說定於一尊嘛，是習自己說的。這個定於一尊的係統有一個特殊的優點，就是在老大的管轄之下，如果他真想讓某一種人的行為停止（病毒他可能力不從心），他一定能做到。一兩年以後，美國這邊的數據，會告訴我們究竟做得怎麽樣。

Interestingly, Biden continues to refer to Xi Jinping as a "dictator." Although this term carries some negative connotations, it's not that bad; it essentially means "holding supreme power," as Xi himself stated. An advantage of such a system of holding-supreme-power is that, under the leader's jurisdiction, if he truly wants to stop certain behaviors (although he may be powerless against a virus), he can certainly achieve it. One or two years later, data from the U.S. will tell us how well he has done.

這次會談的場所是舊金山一個婚禮會館。不知道汪洋同誌對此有什麽新的說辭。據報道，在雙邊會談的間隙，習、拜兩人到院子裏去散了一會兒步，不帶翻譯。於是大家都好奇是如何交流的。要我看，如果心有靈犀，眼神就差不多了；如果雞同鴨講，後麵跟著八個翻譯也白搭。

The meeting took place at a wedding hall in San Francisco. I wonder if Wang Yang has any new rhetoric on this. According to reports, during the bilateral talks, Xi and Biden took a walk in the yard during the break, without a translator. So everyone is curious about how the two communicated. In my opinion, if they have “mind-meld” with each other, eye contact is probably enough; on the other hand, if they are like a chicken and a duck being stuffed into a cage, then even with eight translators, it's futile.

[manually edited from ChatGPT translation.]

 

【圖片來自網上。】