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COMMENTARY

In the United States, we often hear of individuals who blame their misdeeds on ingested substances, be that substance alcohol, crack cocaine, MDMA, or even junk food (as occurred in the farcical but effective “Twinkie defense” in San Francisco).

Be it because they are seeking exoneration, expiation, or simply an explanation, for themselves or others, those individuals hope to receive less onerous sentences, possibly even absolution. Such requests imply that they are repentant, and that they regret the acts that they committed while under the influence, or at least that they recognize their wrongdoings.

Sometimes those results surprise us. Specifically, after Dan White, a one-time police officer and firefighter and Board of Supervisors member, shot both Mayor Moscone and Harvey Milk at San Francisco’s City Hall, psychiatrist Martin Blinder testified that “in susceptible individuals, what we call ‘junk food,’ high sugar content with lots of preservatives, can precipitate anti-social and even violent behavior.”¹ To the shock (and chagrin) of most of those who followed the high-profile legal proceedings, this so-called “Twinkie defense” convinced judge and jury that the shooter did indeed have “diminished capacity.”

Alternatively, when some Manson family members claimed “diminished capacity,” their defense did not succeed—even though their chronic hallucinogen use was well-documented and even though “Tex” Watson produced 8 psychiatrists to testify on his behalf.² That ruling was not totally surprising, when one reviews the statistics regarding the “insanity defense,” for—in spite of the attention showered by the media—not guilty for reasons of insanity (NGRI) pleas are entered in only 1% of felony proceedings. Of those, only about a quarter succeed.^3,4

For the infamous Manson family trials, and the Tate-LaBianca murders, more twists and turns followed. Charles Manson, a career criminal turned cult leader, was convicted on multiple counts of murder even though Manson did not kill anyone himself. Rather, he directed his intoxicated and infatuated followers to carry out his heinous wishes.⁵ This convoluted case—one of the highest profile murder cases in history—eventually concluded because Barbara Hoyt, a nurse and Manson family member, heard Susan Atkins boasting about those horrifying murders. After being fed a hallucinogenic hamburger, in an abortive attempt to murder her and stop her from testifying against family members, Hoyt agreed to testify for the prosecution.^6-8

It is uncommon (but not unheard of) to encounter individuals who brag about their crimes, as Susan Atkins did, since they risk prosecution and prison for those confessions. Yet it is especially uncommon to hear individuals boast that they committed mass murders that are beyond bizarre, and that included beheading babies, or burning alive parents and children, bound by wire, or slicing open the belly of a pregnant woman. That, however, is exactly what happened in the South of Israel, on October 7, 2023.

In one case, a terrorist called his family on the cellphone retrieved from his murdered victim. He gloated, “Look at how many I killed with my own hands. Your son killed 10 Jews.”⁹ As if that were not enough, he offered to forward more grisly images via WhatsApp, images that have not been released to the public because they are said to be so disturbing. Only journalists were allowed to look, so far.

Although that video quickly went viral, it took days, and sometimes weeks, to read reports about captagon tablets (spelled with a small “c”) found on the bodies of Hamas terrorists who died that day, either by military action or possibly because of fatal cardiotropic adverse effects of their meds. By October 20, 2023, All Israel News Staff reported that a “highly addictive drug Captagon [was] found in pockets of Hamas terrorists who committed massacre on Oct. 7.”¹⁰

To date, I know of no one who pinned these horrifying acts on the psychoactive chemicals contained in those pills, be they bootlegged composites of the amphetamine-like psychostimulants, phenethylline (fenethylline), which were probably adulterated with unidentified fillers, or the name brand Captagon that had been banned in the US decades ago, but which retains a vast market in the parts of the Middle East. The demand for either branded Captagon, if even available (or counterfeit captagon, spelled with a small “c”), is great enough to make trafficking immensely profitable.¹¹ In 2020 alone, several sources said that Captagon sales brought $3.5 billion for Syria, an amount 5 times higher than the country’s legitimate exports.¹² The Washington Post states that 80% of the world’s supply of Captagon is produced in the Syrian Arab Republic, with 3 times the combined trade of the Mexican cartels.¹³ A lengthy New York Times article opens with the headlines, “On Syria’s Ruins, a Drug Empire Flourishes.”¹⁴ That article alleges that this pill has turned Syria into the newest “narcostate.”¹⁴

In contrast, some commentators opined that the Hamas atrocities cannot be attributed to those drugs alone, even if those drugs are colloquially called “chemical courage” or “jihadists’ pills,”¹³ said to be favored by terrorists and supplied by their handlers. Sometimes called “the poor man’s cocaine,”¹³ this stimulant also attracts students seeking to pull all-nighters, affluent Saudi partygoers, and impoverished Jordanians who seek escape from the drudgery of daily life. Overworked businesspeople and overnight truck drivers are reputed to be another market.

Writing for the UK-based Telegraph on October 28, 2023, Caroline Rose, a director at the New Lines Institute, a US-based think tank, avers that the “Hamas atrocities have nothing to do with ‘jihadi pill’ captagon . . . Just plain old-fashioned evil, in all likelihood.”¹⁵ Several addiction experts concurred with her conclusions. Psychiatrists from Israel, the US, the UK, even Lebanon,¹⁶ came to similar conclusions, with some saying that attributing the terrorists’ actions to drugs is false because those substances are not fundamentally different from the prescription drugs and party drugs routinely used by individuals who would never think of going on a killing spree.¹⁷ Others admit that very high doses of such drugs can carry more adverse effects.

Why are so many experts so certain of their conclusions, when we know that chemically similar psychostimulants do in fact increase aggression, decrease inhibitions, and obliterate the need to sleep or eat—and even make sleep-deprived users paranoid and poised to attack—especially when taken in excess? Because, for one thing, next-to-no one ascribed their barbarous acts to external influences that were beyond their control. No one denounced the choices they made that day, at least not yet. As Shaul Lev-Ran, MD, head of the Israel Center on Addiction put it, “Substances do not make people cruel. . . People make other people cruel through propaganda and brainwashing. The Hamas terrorists practiced their murderous plan, knew exactly what they were going to do, and took these drugs to help them do it.”¹⁷

Even before October 7, US based psychiatrists dismissed claims that Captagon (or captagon with a small “c”) contributed substantially to Isis’ coordinated attacks on Paris, which left 130 individuals dead and another 350 injured in 2015.¹⁸ Speaking to an interviewer from New York Magazine, Nadya Mikdashi, director of Skoun, an addiction treatment clinic in Lebanon, put it succinctly: “. .. Captagon is not fueling the war in Syria. Politics are fueling the war in Syria.”¹⁹

But what is this Captagon and why should it merit discussion in a psychiatric publication? The banned medicament barely appears in our American pharmacopeia, although references did appear in a few financial journals and Department of Justice (DOJ) bulletins in the past decade or so. The drug, a German discovery from 1961, was never approved for the medicinal use in the United States, and no investigational new drug application was submitted to the Food and Drug Administration.²⁰ It was later listed as a Schedule I controlled substance in the United States and became illegal in most countries in 1986, as per the United Nations Office on Drugs and Crime.

A deep dive is needed to find an entry for Captagon in www.erowid.org²¹ (that encyclopedic catalogue of all abusable and/or psychoactive drugs which ER doctors and amateur psychonauts consult). Its generic name—phenethylline—which is sometimes spelled “fenethylline”—does appear once on the pages upon pages of abusable drugs listed on a UK site, however.²² At least one medical journal author found references on the Dark Web, especially AlphaBay,²³ to which this author is not privy. Those same authors identified sites such as Souq.com, Souqelkhaleej.com, Kingsouq.com, Halalat.com, Aliexpress.com, Araboo.com, and Sa.pricena.com as depositories of information about Captagon, including drug purchase materials, books, documentaries, chemical analysis data, plus irrelevant results.²⁴

A deeper internet search unearthed a short 2003 document from our DOJ. Although it is 20 years out of date, it is still worth reading.¹¹ As the time lag suggests, captagon’s profile in America’s illicit drug market remains low—but a retired government official mentioned below hints that this is subject to change.¹¹ Others posit that captagon’s profile is so very low that that inspectors are not likely to recognize it on sight.

So where do we go from here?

Since I am not a political analyst or a military strategist, and am not schooled in international trade, licit or illicit, I cannot claim expertise on economic backchannels or on the nuances of war—or on the many other important but tangential issues referenced above. So, I will restrict myself to topics that fall under my purview, specifically psychiatry and psychopharmacology (with some references to film and psychiatry). I will confine further comments to this mysterious substance alone.

Films & Pharmacology

Considering that the substance is a stimulant, synthesized from amphetamine and theophylline pro-drugs, with low-cost raw materials and simple laboratory equipment, and that it is distantly related to methamphetamine, I thought of Jacob’s Ladder.²⁵ In Jacob’s Ladder, a capable—but criminal—young chemist is cajoled (or blackmailed, to be more accurate) into synthesizing a chemical that could increase aggression in soldiers, and presumably help his country win the war in Afghanistan. Pressed by seedy CIA operatives, in a trope that has become a cinematic staple, the chemist succeeds in creating a substance that is so strong that the troops turn on one another, even before entering the battlefield and encountering their designated enemies. They murder their comrades in the most vicious ways possible, while the titular Jacob Singer has no conscious recollection of those events at all.

Let me turn to a more current creation that ran between 2008 and 2013 and that is only a decade out of date—but is directly related to the topic of illicitly synthesized and chemically related stimulants: Breaking Bad. This show revolved around clandestine meth manufacture, conducted by a previously upstanding high school chemistry teacher who is stricken with incurable cancer and desperately concerned with leaving funds for his family. Walter White, played by Bryan Cranston, enlists the help of his pot-smoking student who previously strayed from the straight-and-narrow. They traverse a path that leads to murderous Mexican cartels, and that keeps audiences riveted for 6 seasons and a few spinoffs. In 2006, shortly before this hit series aired, the United Nations World Drug Report had already condemned methamphetamine as “the most abused hard drug on Earth.”²⁶

A much more recent movie turned out to be even more on point—and eerily contemporaneous to the tragic occurrences on October 7. The Equalizer III, the latest entry into The Equalizer franchise, was released in the US in September 2023. The action-adventure film, directed by Antoine Fuqua, stars Denzel Washington as Robert McCall, an ex-Marine and a recently retired government operative. McCall is seeking an uneventful life in a sleepy village on Italy’s Amalfi Coast. Although the protagonist is essentially the same character as portrayed in previous films, the framing device of this film—as well as the resolution—revolves around smuggled phenylethelline, the generic name for Captagon.

Tellingly, when McCall stumbles on an Italian winery that is stocked with imported wines, he wonders aloud why Italy, a country known for its wines, would need to import wines. When a bottle breaks, and phenylethelline pills spill out, it is evident that the wine bottles are only a ruse. Perhaps this references the unusually large seizure of captagon pills from an Italian port, when port officials intercepted a $1.1 billion shipment of the drug from Syria in July 2020.²⁷ Some credible sources speculate about links to the Italian Mafia, as depicted in this supposedly fictional film.²⁸ Similar contraband has been confiscated from lemon or orange shipments, in real life, and in cans of green beans, bags of flour, pomegranates, grapes and more.¹²

Pharmacology and (Il)Legality

Captagon’s history may not be as riveting as The Equalizer franchise, but it is interesting in and of itself—and it does have its own dark history. Captagon was the brainchild of a German pharmaceutical company Degussa AG, which synthesized Zyklon-B, the gas used by Nazis to exterminate Jews in the “Final Solution.” Degussa also received and smelted gold teeth, caps, and fillings extracted from Jews before, or after, their murder.²⁹ The company still operates, but under a different name and ownership.

The medicament was originally intended as a treatment for “hyperkinesis” (the forerunner of attention-deficit/hyperactivity disorder), depression, narcolepsy, and other indications. Captagon became the best-known of several brands of the same amphetamine-like stimulant. Other brand names included Fitton and Biocapton.

Phenethylline/fenethylline is controlled in the United States under Schedule I, meaning it has no accepted medical use. Official production ceased after the World Health Organization listed fenethylline for international scheduling under the Convention of Psychotropic Substances in 1986. Although authentic branded Captagon no longer exists, the term captagon refers to tablets pressed with the Captagon logo. Those counterfeit pills contain a wide range of substances, including fenethylline, amphetamine, caffeine, and other adulterants. Some such pills are stamped with a double crescent moon; others, with swastikas.³⁰

Almost prophetically, a few months before the captagon-fueled tragedy on October 7, allusions to Captagon appeared on www.drugs.com. On April 5, 2023, someone queried, “what exactly is captagon, and why was it banned?”³¹ In response, it was touted as “the jihadists’ drug” or “the amphetamine fueling Syria's war."³² No mention was made of Hamas or Hezbollah or Isis. A month later, in May 2023, Arab nations readmitted Syria into the Arab League, in exchange for a promise to terminate production and smuggling of Captagon, which endangered their citizens. Previously, Syria was temporarily blocked from membership because of its links to Captagon.

Two months later, on June 9, 2023, the United States Department of State published “Report to Congress on A Written Strategy to Disrupt and Dismantle Narcotics Production and Trafficking and Affiliated Networks Linked to the Regime of Bashar al-Assad in Syria.”³³ This lengthy document is too detailed to summarize here, but may be useful to many readers who seek such specialized data. The State Department clearly implicates the regime of Syrias’s President, Bashar al-Assad, or his relatives, even though President Assad himself denies involvement with the drug. Bashar is a scion of the al-Assad family dictatorship in Syria. Ironically, Bashar al-Assad began his professional career as a physician who pursued postgraduate specialty training in ophthalmology in Britain. Since ascending to political power, he stands accused of engaging in murderous activities against his own countrymen and against ethnic minorities, and chemical warfare against civilians,³⁴ all of which are activities that directly and dramatically contradict the healing role that he laboriously prepared for as a physician.

Questions about Captagon and terrorist activities were not entirely new. Related questions had been raised years earlier, particularly in response to murders perpetrated by Isis in 2015. Writing on November 21, 2015, Yaniv Kubovich, a reporter for Haaretz, a long-running liberal Israeli newspaper, commented about “Breaking Bad: The Stimulant Drugs That Link ISIS and the Nazis.”³⁵ On May 12, 2017, Mirren Gidda opened a Newsweek article by asking, “Drugs in War: What is Captagon, the 'Jihad Pill' Used by Islamic State Militants?”¹⁶ Among other things, the article quotes a former militant who spoke to CNN in 2014, stating that ISIS "gave us drugs, hallucinogenic pills that would make you go to battle. . .” It links to a chattier New York Magazine Intelligencer article, where author Sulome Anderson interviews candid contributors to the Captagon trade. An informant whom she quotes in an article entitled, “These Are the People Making Captagon, the Drug ISIS Fighters Take to Feel ‘Invincible,’”16 explains, “We take a chocolate machine and put a small mold in it for making sweets” . . . “Then we put the ingredients in and let them harden to make the pills.”¹⁹ Three months earlier, officials across Europe had intercepted thousands of bootlegged black market captagon pills.

Clearly, there has been a lot of buzz about Captagon outside of the US. Some say that Captagon’s properties have been mythologized and that hyperbolic accounts of its effects are essentially clickbait. Still, despite all the reports about Captagon that are scattered about online, no one has suggested that Captagon is the first psychostimulant used for warfare or that ISIS or Hamas terrorists stake a unique claim to mind-altering medicaments. Rather, historians and others acknowledge that fighters in both World Wars, certainly in Vietnam, and even the Civil War, had access to psychoactive substances, and that Japanese kamikaze pilots were medicated before missions. Moreover, military medicaments are not exclusive to warzones; a 2007 survey of a US Army special operations unit found that about a quarter of soldiers took anabolic steroids to increase muscle mass, and [supposedly] to speed recovery from injury.³⁶ It seems that Captain America’s “secret soldier serum” was not so secret after all.

Current Events & Captagon

Apparently, some individuals in the US were concerned with risks related to captagon, for President Joe Biden signed the “2022 US Captagon Act” (HR 6265 Captagon Act) into law just before Christmas, on December 24, 2022. The bill was proposed by the House Foreign Affairs Committee. That act linked the trade to the Syrian regime, calling it a “transnational security threat.” The business of Captagon commerce had already intrigued respected financial journals, for on November 2, 2022, Barron’s website published an AFP article on “What is Captagon?”³⁷

Possibly in response to Biden’s bill, financial outlets, such as Barrons, The Economist and Bloomberg, published articles on the topic. Even before their stories hit the press, CNN informed audiences on April 11, 2023, that “A little-known drug brought billions to Syria’s coffers. Now it’s a bargaining chip.” CNN stated that captagon is “relatively unknown outside of the Middle East,” but the industry’s growth has raised alarms.³⁸

On May 9, 2023, Reuters wrote about “Captagon: the drug fueling the Gulf party scene – and Syria’s finances.” The news source proceeded to say that, “As early as 2014, Syria was thought to be a major producer and consumer of the drug, and fighters including militants of the Islamic State group were thought to consume captagon to stay awake on frontlines. Some press releases contend that “Captagon [production/distribution] is supported by Hezbollah,”^39,40 although Reuters remarks that “Hezbollah denies links to drug kingpin killed in Syria.”⁴¹

The Economist, which has published more than one article on the topic of captagon, began its May 9, 2023, entry with the words, “After twelve years of blood, Assad’s Syria rejoins the Arab League.⁴² It notes the role Captagon played in removing and readmitting Syria to the League. It also describes Assad as “one of the 21st century’s worst war criminals.”⁴² Two days later, on May 11, 2023, The Economist expands on the topic in an article headlined with the words, “The rehabilitation of Syria’s dictator raises awkward questions for the West.⁴³ This article asserts that over 300,000 Syrian civilians had been killed since 2011 and… Some 6 million citizens have been displaced inside Syria; a similar number have fled the country.

Come late summer, Bloomberg’s newsletter, dated August 21, 2023, warns that “’The Poor Man’s Cocaine’ May Threaten Europe Next.”⁴⁴ It notes that Al-Assad and his Lebanese ally Hezbollah “are trying to tap new markets on the [European] continent in response to shifting politics and a crackdown in the [Middle East] region.” This website makes no mention of yet another frontier—the US—where shortages of stimulants sought by many Americans,⁴⁵ and especially by “Generation Adderall”⁴⁶ (to use New York Times’ 2016 moniker for millennials), may offer even bigger opportunities.

Given that references appear on the Dark Web, according to a medical journal article written by authors affiliated with the American University of Beirut,¹¹ we cannot predict if or when this drug will enter the underground American marketplace. Jim Crotty, former Deputy Chief of Staff at the US Drug Enforcement Administration, rang an ominous warning bell on September 21, 2023, just weeks before the October 7 attacks. The former Deputy Chief frets that the US is ripe for another drug epidemic, this time, of energizing drugs, such as stimulants.

Applying a broader overview of drug trends—broader than the more focused view used by those of us who treat patients, day in and day out, Crotty reminds us that, “substance abuse tends to move in cycles. Periods with high rates of depressant drug use (like opioids) are almost always followed by ones with high rates of stimulant drug use (like methamphetamine and cocaine), and vice versa. The heroin crisis of the 1960s and 1970s was followed by the crack epidemic of the 1980s and 1990s, which gave way to the current opioid epidemic. Methamphetamine use is already on the rise. Will captagon be next?”²⁴

Dr Packer is an assistant clinical professor of psychiatry and behavioral sciences at Icahn School of Medicine at Mount Sinai in New York, New York.

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