Walk into any craft beer bar in San Francisco, and the menu provides an endless amount of useful information. You can select your beer based off flavor, glass size, or percentage of alcohol. If you drink too much and get sick, someone who works in the bar will likely provide some basic care, call you a car home, or — in worst-case scenarios — summon the paramedics.
The regulation of alcohol, the transparency over what your drinks contain, and the safe-consumption spaces in which you enjoy them are a privilege. But if you live on the streets and your drug of choice is black tar heroin instead of a nine-percent ABV IPA beer with Citra hops, the risk of using is much, much higher. As the majority of drugs sold on the street are unregulated, it’s a crapshoot what the ingredient list contains at any given time. And the supply is a constantly evolving beast, with one source providing different blends of product from one week to the next.
“When these substances became criminalized and thus unregulated, they became and remained risky,” says Miss Ian Callaghan, executive director of the San Francisco Drug Users Union.
That risk is no small thing. In San Francisco, a recent change in supply combined with a number of other social factors has led to a spike in overdose deaths. From July 30 to Sept. 18, 25 people died from what appears to be drug overdoses in the city. Fifteen of those occurred during the first two weeks of September alone. With between 100 and 125 citywide overdose deaths reported annually, this spike stood out. The first to notice was the city’s chief forensic toxicologist at the Medical Examiner’s office, Dr. Luke Rodda.
Rodda has the tools at his disposal to help identify overdoses. The brand-new, $65 million Medical Examiner’s office has a state-of-the-art forensic toxicology lab, able to test blood, urine, and autopsy samples for levels of a specific drug. But these samples take time to process, and while the deaths can’t be 100 percent ruled an overdose until then, preliminary information can still be disseminated to the community to prevent potential public-health crises. Information gathered by the office’s death investigators — such as drug supplies nearby and witness statements — can be used to paint a picture of a trend before toxicology reports are finalized.
Of the 25 people showing signs of overdose whose blood he tested since July 30, more than 20 contained just fentanyl. This gave Rodda a clue as to what was going on.
“We’ve known for many years now that there’s been a movement of fentanyl to be substituted altogether for heroin,” he says. “These numbers show that.”
Once a trend is identified, Rodda has a team of people on speed dial that he notifies: The Department of Public Health, San Francisco General Hospital, the California Poison Control Center, and the Drug Overdose Prevention and Education (DOPE) Project.
At the DOPE Project, Eliza Wheeler and Kristen Marshall are the ones who receive these calls and kick into gear a tried-and-true method of getting the word out to those most at risk for overdose. First, they contact frontline workers — those who staff needle exchanges or health clinics that treat people who use drugs — and let them know there’s been a recent rise in deaths. That information is then passed along to people who use. (Many of whom may already be aware. After all, people talk.)
Instead of creating a scary alert that can spur short-term hysteria, the DOPE Project focuses on its universal precaution messaging: Use less, use slower, and don’t use alone. Have naloxone, the overdose reversal drug, on hand, and make sure a friend checks on you as you use. Changes in supply don’t have to equal instant death.
In this summer’s case, the messaging appears to have worked. Overdose fatalities appear to have decreased after the initial rise in the first half of September. Samples tested continue to be positive for fentanyl, so it’s possible that the supply has stayed the same, but users’ behavior has adjusted to better handle the drugs.
That’s good news, but behind the scenes, experts are still trying to figure out what was going on. The DOPE Project partnered with a clinical lab to do its own sample testing and found that significant amounts of cocaine had been mixed into opioids, which meant that people who purchased what they thought was black tar heroin or fentanyl were also unknowingly consuming a stimulant. (The Medical Examiner’s office found the same thing.) While this combination of drugs is not uncommon — it’s often called a speedball or goofball — combining drugs can raise the risk of an overdose, which could have contributed to the summer’s spike in deaths.
“We can’t make complete conclusions, but it may suggest fentanyl-laced cocaine and fentanyl-laced methamphetamine,” Rodda says. “People who’ve been using heroin for some time and then have additional fentanyl on top may be able to sustain it and not have an overdose. These populations who are more opioid-naive, they’re certainly more susceptible.”
But nothing in San Francisco happens in a bubble, and a simple shift in street-drug ingredients isn’t the only cause of the recent spate of overdoses. Marshall says it’s just one piece of a larger social issue. In San Francisco, we have homelessness, displacement, and poverty — and on top of that, she points out, the city has seen an increase in sweeps of homeless camps in recent months that affect public health. Frontline workers say they’ve seen a spike in requests for naloxone, not just because it’s being used to reverse more overdoses, but because unhoused people are having the medicine thrown away by Public Works employees, meaning that if someone overdoses they no longer have the tools to reverse it.
“You have all of this happening in the Downtown Civic Center area, which is ground zero for 311 calls,” Marshall continues. “It isn’t just fentanyl that’s doing this. It isn’t just injection drug use. It isn’t just homelessness, it isn’t just the punishment by the city — it’s all of those things happening all at once.”
Callaghan of the Drug Users Union agrees.
“People have been mixing uppers and opiates for centuries, and the overdose epidemic increases mostly because of the many tiers of criminality, stigma, hopelessness, and trauma without access to resources, not necessarily because fentanyl exists,” Callaghan says.
That makes solutions to the recent spate of overdoses harder to identify. In some ways, a change in drug supply is the easiest battle to tackle, in part because it’s been seen before. When fentanyl first hit San Francisco en masse in 2015 Rodda wasn’t employed by the city, and it was the people who used drugs who first raised the alarm. Marshall worked at the Sixth Street Harm Reduction Center at the time.
“I walked around the corner to open up on a Saturday, and we had a line,” she says. “We never had a line — we’re open for eight hours. Why would anyone line up? When I walked up everyone started talking at once. ‘Everyone’s overdosing!’ they said.”
People were administering naloxone in numbers no one had seen before. That day, Marshall emailed her site supervisor, who forwarded the email to the DOPE Project, which then began interviewing people who used drugs and got samples tested. They found fentanyl, which had slowly been moving west from the East Coast. Just a few days after Marshall was confronted with a line of people outside the needle exchange, outreach workers were patrolling Civic Center, educating people about fentanyl and handing out naloxone.
Months later, “we were hearing the same reports, but people were surviving,” she says.
Fentanyl’s presence in San Francisco isn’t likely to dissipate anytime soon, but as the city and people who use drugs learn how to better respond to its fluctuations, overdose deaths may not necessarily rise. Nevertheless, many of those who use street drugs in San Francisco are a vulnerable population, and until they regain some of their basic human rights to live, work, and sleep in our city, their public health will suffer.
Nuala Sawyer is SF Weekly’s news editor.
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