On Sept. 24 of last year, Joseph Briones and a friend walked into the Westfield Centre mall on Market Street and headed towards the bathrooms, in search of a safe place to get high.
The pair, heroin users with no fixed addresses, knew that the upscale mall has toilets off the beaten track.
Briones went into a stall and prepared his shot. It was his last. By the time his friend realized that Briones had overdosed, mall security was on the scene. The friend pleaded with security to be allowed to give his friend another shot — this time of naloxone, the overdose antidote that's sold under the brand name Narcan.
Whether out of ignorance or a liability-averse mall policy, the mall cops refused, according to the story repeated to me by a former member of the S.F. Drug Users Union. Briones died. He was 32 years old.
That was almost 14 months ago, but there's still no official cause of death for Briones. The Medical Examiner's Office has yet to process his file; the fact that Briones was a street person may have something to do with the delay. But the street knows the reason. Briones took a shot of heroin laced with fentanyl, the synthetic opiate that's led to an unprecedented increase in overdoses, and is now appearing in other street drugs.
Fentanyl is a synthetic opiate designed for advanced-stage cancer sufferers in acute pain. It's “50 to 100 times” more powerful than morphine, according to the Centers for Disease Control and Prevention, which sent out an advisory on fentanyl earlier this week.
Whether it's illegally diverted shipments from pharmaceutical companies, stolen fentanyl patches, or fentanyl cooked in labs, there's a nationwide trend afoot. The nation's drug cops have reported a huge boom in seizures of the drug from 618 seizures in 2012 to 4585 last year. If the “10 percent” rule — cops seize 10 percent of what's on the street — is true, fentanyl-tainted drugs appears to now be a considerable problem.
Briones' preventable death aside, this is (for now) a mostly positive story. Fatal heroin overdoses in San Francisco have been on a steady decline from the early 2000s, when the city averaged more than 100 per year. Now it's closer to five or 10 per year, according to the DOPE Project, a harm reduction advocacy group that works with the city's intravenous drug users.
People are still overdosing: about 30 to 35 overdose reversals are reported every month. But something changed this summer. Things got bad. There were 109 overdoses reported in August — all of them reversed with a shot of naxolone, the user's life saved.
“That's the most we've had in one month,” says Eliza Wheeler, executive director of DOPE Project. “People were just Narcanning their friends left and right, sometimes multiple times a day.”
Heroin use is on a slight upswing nationally, the result of cops shutting down “pill mills” where doctors write prescriptions for opiate-based painkillers willy-nilly. Wherever a pill mill closes, enterprising narco-traffickers arrive to service the drug users who are now bereft of a heroin supply — a fascinating tale of underground capitalism told in detail in journalist Sam Quinones's recent book, Dreamland.
The deadly twist is that fentanyl is now appearing in other drugs sold on the street, bought by people unfamiliar with heroin culture and inexperienced with reversing an overdose.
The country's most abused drug is prescription medication, and somebody is distributing fake Xanax laced with fentanyl in San Francisco, according to the Department of Public Health.
At least four people have been sent into an opiate overdose after popping the bunk Xanax, according to DPH, including one person found dead with a fentanyl-laced Xanax nearby.
This is troubling. Heroin users are prepared for an overdose in a way pill users are not. Though Narcan has never been more readily available — you can buy it at CVS without a prescription — the knowledge that a pill user should be prepared for an overdose is not.
Fentanyl is not new in San Francisco. However, according to anecdotes from users and advocates, it appears to be here in a new way. “It used to come in waves,” Wheeler says. “Now we're just seeing it consistently more in place.”
The city has done a good job managing its opiate problem. DPH was an early adopter of naloxone, which has been distributed for over a decade among the city's heroin users, whose mortality rates improved. But this latest development suggests that everyone who uses prescription medication needs to have an overdose kit handy — as well as the knowledge that that $5 anti-anxiety pill might have fake heroin inside.