Fentanyl: The City’s Biggest Public Health Crisis

While San Francisco largely managed to keep coronavirus under control, overdose deaths in the city, many attributed to fentanyl, have skyrocketed.

Dusk was falling on Polk Street when we came across a man lying motionless on the sidewalk, his face pressed against the pavement. At first we kept walking, choosing to believe he was sleeping. But then we hesitated.

Heather Knight’s Chronicle column about the man who died of an overdose in broad daylight had just been published, and I was in the midst of reporting my own story on the city’s drug epidemic. To ignore what we had just seen, to simply step around this man, would make my girlfriend and I complicit in what might have been yet another death on the streets of the Tenderloin.  

I went back to where the man was lying and naively yelled, “Are you OK?”

No response. A passerby who appeared to have some experience in this kind of situation stooped and listened for the prone man’s breathing. It was strong, he said. He shook the sleeping man, and he responded, ever so slightly. That was enough for the Good Samaritan, who left, but not for us novices. Sarah had heard that you can call 311 for emergencies that don’t require police interventions. She dialed. 

The ambulance arrived in less than five minutes. The paramedics were able to rouse the man, it seemed, and thanked us for calling. We hesitated again and went on our way, back to the parallel universe from which we’d come, the San Francisco where it’s possible to largely ignore the thousands of overdoses and hundreds of overdose deaths that have turned this city into an epicenter of America’s opioid crisis. 

Our experience — a daily, if not hourly one, in some corners of the city — was suffused with the same question that now confronts everyone in San Francisco as this crisis continues to escalate: What should we do?

There are no easy answers.

There is a growing acknowledgement among city leaders that San Francisco’s pioneering harm reduction approach may not be enough, on its own, to stem the tide of deaths by fentanyl, the drug at the root of the overdose epidemic. But there’s also a profound — and justified — fear of returning to the punitive and racist tactics of the War on Drugs. Somehow, the city needs to build on its existing strategies and also find a way to reduce the availability of a substance that some say is more akin to a poison than a recreational drug, without repeating the devastating mistakes of the past. 

“Many of the programs that we have are not effective in the face of fentanyl,” says Supervisor Matt Haney, who represents the Tenderloin and SoMa. “That’s true for harm reduction, that’s true for treatment, that’s true for law enforcement. They’re not built for the deadliness of fentanyl.”

How these systems should evolve to meet the current challenge is still a matter of vigorous debate, although there are already major efforts underway at different levels of government. As these discussions continue in the coming months, the city’s largely successful fight against COVID-19 could prove to be a valuable template. If San Francisco is to turn the tide on its overdose epidemic, it will likely take a similarly comprehensive, all-hands-on-deck approach that is commensurate with the growing death toll.

The Scale

Each person who dies of an overdose has a name and a story. Reducing them to statistics doesn’t do justice to their memories. But looking at the data in aggregate is necessary for public health and government officials. It is important for the public, too, as it helps us wrap our minds around this crisis, and pursue policies that will lead to fewer deaths on our streets and in our neighborhoods. 

In terms of loss of life, San Francisco’s drug overdose epidemic is several times more severe than COVID-19. In 2020, the city recorded 258 COVID-19 deaths and 713 drug overdose deaths. About two thirds of those overdose deaths involved fentanyl. This year is on track to be even more deadly. In the first three months of 2021, the city saw 203 overdose deaths. For context, during that same time period, nine homicides were reported in the city. 

Overdose deaths in 2020 were heavily concentrated in the Tenderloin, SoMa, and the Mission, according to the Office of the Chief Medical Examiner. More than 80 percent of people who died of an overdose were men, and nearly 30 percent were homeless. A quarter of people who died of an overdose were Black, a community that makes up just 6 percent of the city’s total population. 

Fentanyl’s deadly rise has happened fast, with overdose deaths tripling between 2018 and 2020, leaving drug researchers, public health officials, and frontline service providers scrambling for answers… and solutions. “We’re about as bad as any city in the country at this point in terms of overdose deaths,” says Alex Kral, an epidemiologist at the non-profit research institute RTI International based in San Francisco. 

It is a particularly painful reckoning for San Francisco, not just because of the sheer human toll, but because of how successfully the city’s harm reduction model had been at reducing drug overdose deaths in the past: In a matter of just a few years, San Francisco went from being an exemplar in the field of drug overdose prevention, according to researchers, to one of the hardest-hit places in the U.S., on par with opioid crisis hotspots like rural Ohio and Philadelphia. 

The Opioid Crisis

San Francisco may be unique in terms of the scale of its fentanyl problem, but the city is hardly alone. Opioids, and fentanyl in particular, are driving an escalating epidemic of overdose deaths nationwide. 

In 2000, a few years after OxyContin began being widely prescribed by doctors, there were approximately 20,000 overdose deaths in the U.S. By 2016, that figure had climbed to 50,000, as an ecosystem of illicit opioids sprang up to serve all those who had become addicted to prescription painkillers. Cheap and easy to produce, fentanyl emerged into this marketplace about five years ago, making an already dire situation worse: In 2019, the U.S. recorded 72,000 drug overdose deaths. 

Then came the pandemic, causing an uptick in depression and joblessness, and a decrease in treatment opportunities and relatively safe places to use. In the 12-month period ending in September 2020, the U.S. saw more than 90,000 drug overdose deaths, according to preliminary CDC data, with fatalities markedly increasing starting in March. 

While deaths from meth and cocaine have also been on the rise, the real difference-maker in recent years has been fentanyl. In fact, growing mortality rates for other drugs are likely driven at least in part by fentanyl, which producers sometimes combine with cocaine or heroin and sell to unwitting customers. It’s also becoming increasingly common for people to mix fentanyl and meth on purpose.  

When the opioid crisis began, its epicenter was economically depressed parts of the Northeast and Midwest. Fentanyl hit these places first, too, because the heroin sold there comes in a powder form, making it easy to mix with fentanyl, in contrast to the West Coast’s “black tar” form of heroin. But over the past couple of years, fentanyl has achieved a significant drug market share on the West Coast nonetheless, with overdose deaths rising in tandem. 

Despite brief spikes in the preceding years, it wasn’t until the fall of 2018 that fentanyl became its own standalone street drug in San Francisco, according to Kristen Marshall, executive director of the Drug Overdose Prevention and Education (DOPE) Project, which distributes overdose reversing drugs like naloxone, also known by its brand name, Narcan. 

In 2019, California saw the fastest-growing rate of drug overdose deaths of any state. And within California, San Francisco has become one of the hardest-hit counties. San Francisco was second only to rural Lake county in opioid overdose deaths per capita in 2019. Last year, the trends only accelerated, Marshall says. 

“By the end of March it had spiked so dramatically that when I got a graph and looked at the numbers I felt like I was gonna throw up.” 

What is Fentanyl? 

Even as the word “fentanyl” increasingly dominates headlines, public understanding of what it is and what it does to the human body is limited to the bare essentials: it is an opioid and it is killing people. A more complete understanding is crucial to making informed decisions about how to address this crisis. 

Fentanyl’s most important attribute is its potency. Its thousands of forms range from 50 to 100 times more powerful than morphine, placing it at the top of the opioid food chain. To use an imprecise metaphor: If raw opium is beer, codeine and morphine are wine, and heroin is whiskey, then fentanyl is 195-proof white lightning.

In a supervised medical context, fentanyl’s high potency and short duration can be beneficial. The substance has been approved for medical use in America since 1968, most often as part of an epidural cocktail — like those administered to women giving birth — or an acute pain reliever during surgery.

“Now, on the street, all that’s bad. Because it’s too strong for the street,” says Dan Ciccarone, a drug researcher and professor of family and community medicine at UCSF. Bad for people who ingest it, that is. But for producers and dealers, fentanyl offers several advantages. 

Read More: Learn about Calamity Fair’s artwork for the cover of our May 6, 2021 issue on fentanyl — the city’s biggest public health crisis.

As a synthetic opioid, rather than a naturally derived opiate like heroin, fentanyl is less labor-intensive to make. Producing heroin requires poppy grows that need to be guarded, harvested, and processed. Fentanyl, by contrast, can be synthesized in a relatively simple lab using base chemicals that are legal in China and available for purchase on the dark web.  

The resulting white powder substance is easy to mix into other drugs. And because it requires so little of the physical substance to get users high — doses are measured in micrograms — it is far easier to conceal or smuggle a massive payload.

It is possible to overdose on any opioid, but fentanyl’s potency and short duration significantly increase the risk. “Micrograms are hard to measure,” Ciccarone says. “You’re running Russian Roulette with every shot you take.” 

When a person overdoses from opioids, “a number of dials get turned down,” Ciccarone says. “Your consciousness dial gets turned down, your respiratory drive gets turned down, and your cardiovascular pumping system gets turned down. So some combination of those three causes you to lose consciousness. And if that goes on for too long, then you go comatose, and then you’ll die.”

With fentanyl that whole process happens a lot more quickly than it does with other opioids, meaning fentanyl overdoses are harder to reverse. There is typically a 10 to 30 minute window to revive someone who has overdosed on heroin using overdose reversal drugs like Narcan. For someone who has overdosed on fentanyl, that window is closer to five minutes. 

Linda Mantel with Glide Harm Reduction shows a strip that determines whether fentanyl is in a user’s heroin at a safe injection site simulation at Glide Memorial Church’s Freedom Hall on Wednesday, Aug. 29, 2018. Photo by Kevin N. Hume

Thomas Wolf, who was unhoused and addicted to opioids in 2018 and now works as a drug policy advocate, recalls fentanyl’s profound effect on him, despite his high tolerance for opioids. “I took two hits off of foil and for the next four hours I was unable to control my leg movements,” Wolf says. “I kept bumping into walls as I’m walking down the street, fell down a couple of times, and eventually ended up slumped in a doorway for about two hours.” 

Wolf also notes that withdrawals from fentanyl are worse than for heroin and other opioids, rendering withdrawal suppressants less effective against them. “If the fentanyl is 10 times stronger than heroin, it means that withdrawals are 10 times stronger on the back end,” he says. “And so you really just become a slave to it.”

An S.F. Problem?

How San Francisco became an opioid hotspot “straight out of Dayton, Ohio, straight out of Lynn, Massachusetts,” in Ciccarone’s words, is still being studied. But there are a few baseline facts researchers and service providers have established.

The first is that in San Francisco, fentanyl is typically marketed and sold as fentanyl, setting it apart from other cities where fentanyl is more likely to be used to boost the potency of heroin, sold as counterfeit prescription pills, or mixed with other drugs. And that shift — from fentanyl as additive or adulterant to fentanyl as the advertised product — did not happen by accident.

“We don’t have a bunch of fentanyl in San Francisco because all of our drug users just woke up one day and were like, yeah, that’s what we want,” Marshall says. “They were responding to the market.” 

Given the distribution and manufacturing advantages it enjoys, fentanyl has been something of a disruptor in the marketplace. Since the mid-1980s, when Alex Kral began researching San Francisco’s drug market, the dynamics were “pretty much completely stable. It just wasn’t that interesting to look at.” About 70-80 percent of people were injecting heroin, and 30-40 percent were injecting meth, with about 10 percent overlap.

“Over the past three years, it has completely shifted with this fentanyl thing.” In his latest surveys, Kral is finding that over half of people who use hard drugs are using meth and fentanyl combined, also known as a goofball. The combination helps people stay awake and actually function during their fentanyl high. 

The most prevalent form of fentanyl ingestion in San Francisco is probably smoking, which is not common elsewhere in the country, researchers say. That could be a good thing when it comes to reducing overdoses. On a recent Zoom call with 70-80 drug researchers, “everyone on the call” agreed that smoking fentanyl is less dangerous than injecting, Ciccarone says. 

Kral is more skeptical. “You might have a little bit more control over how much you’re actually taking in” when you’re smoking, Kral says. “That said, given that we’re having so many overdose deaths right now in San Francisco, I don’t know how that’s related to [the smoking] or not.”

One thing that’s clearly linked to the increase in overdoses is the isolation brought on by the pandemic, and other changes to people’s routines. If “one day, you decide to use somewhere else in a different environment of some sort, that setting matters,” Kral says. “The exact same amount of the drug that you’ve taken could now cause you to overdose.” Kral also says that as San Francisco’s population has grown, and more abandoned industrial areas have been transformed into office and residential neighborhoods, people who use drugs have fewer private places to go. “So what they’re doing then is they’re rushing their use. Because the less time I spend doing the drug, the less time I’m exposed to police, neighbors, and so forth.” 

There’s also a connection between high drug mortality rates and using drugs alone. Sheltering in place — whether in your own home, or, for unhoused people, in a tent or a shelter-in-place hotel — and reducing social contact significantly increase the risk of drug overdose. “All these strategies to prevent the spread of COVID 19, most of those things are completely paradoxical to the strategies you use to prevent overdose,” Marshall says, “and most of that has to do with isolation.”

A Harm Reduction Pioneer 

San Francisco has long been a proving ground for innovative strategies to prevent drug overdoses, becoming a standard bearer of the harm reduction approach to drug policy. Rather than criminalizing drug users, or even dealers, in some cases, harm reduction seeks to reduce people’s risk of overdose, and engage them via treatment, not the criminal justice system. Instead of cutting off people’s access to drugs and expecting people to simply quit, harm reduction policies and treatment methods give people the opportunity to use drugs safely, and begin to quit when they’re ready.

In the ’90s and early 2000s, public health advocates in San Francisco were some of the first in the U.S. to pioneer clean needle exchanges and naloxone distribution programs. These efforts became formalized and city-sanctioned through organizations like the DOPE Project, which was founded in 2003 and has since become the largest single-city naloxone distribution program in the country. 

As for the impact of these efforts, the data speaks for itself. The number of heroin-related overdose deaths in San Francisco went from about 120 in 2000, to about 10 annually between 2010 and 2012. 

There are many indications that those very same programs are preventing San Francisco’s current overdose crisis from getting even worse. “Even though we see an ever increasing rate of overdose deaths, we’re also seeing a drastic and ever increasing and exponentially higher rate of overdose reversals, which is when someone who overdoses is administered Narcan, and then they survive,” Marshall says. 

From January to the first half of August 2020, the DOPE Project recorded 2,155 reversals done by people who received their overdose reversal drugs. Those numbers are probably a dramatic underestimate of actual overdose reversals, as recorded reversals likely represent only about 20-30 percent of reversals being done by “laypeople,” Marshall says. Police, paramedics, and even BART police have also been increasing their number of overdose reversals, but these figures pale in comparison to the number carried out by Narcan recipients from the DOPE Project. 

More Work To Do

In addition to expanding naloxone distribution, another low-lying fruit for drug intervention researchers and advocates is making it easier for doctors to prescribe opioid treatment drugs that reduce cravings and minimize withdrawal symptoms. Until last week, drugs like buprenorphine — a key ingredient in Suboxone, which functions in a similar fashion to methadone, staving off cravings for a prolonged period of time and blocking the effectiveness of other opioids — could only be prescribed by doctors who have taken a special, $800 course, and then only to a limited number of patients.

“You don’t have that for blood pressure medication or chemotherapy or anything else basically,” Kral says. “Having way, way more access to buprenorphine out there would get a lot more people to be well enough that they don’t need to use opioids and therefore not be overdosing.” 

On April 27, Xavier Becerra, Secretary of the Department of Health and Human Services, and former California Attorney General, loosened some of those restrictions, allowing nurses and physicians who are licensed to prescribe controlled substances to prescribe buprenorphine without taking a special course. It also allows practitioners to apply for a waiver to treat more than 30 patients at a time. 

Yet another potential solution on the horizon is the legalization of safe consumption sites, also known as safe injection sites. In 2018, the state legislature legalized a safe injection site pilot program in California, but it was vetoed by then-Governor Jerry Brown, citing fear of prosecution by the Trump Administration. San Francisco’s state Senator, Scott Wiener, is trying again this year, with more confidence that the idea will be welcomed by Governor Newsom and Secretary Becerra, who supported safe consumption sites as California AG. 

While it’s likely that San Francisco would see just a handful of such sites at first, Kral would like to see them in every SRO. Well before the pandemic, in the late ’90s Kral’s research found that 68 percent of heroin overdose deaths took place when an individual was alone, and 47 percent of those deaths took place in SROs.

Mayor London Breed picks up a user kit during a tour of a safe injection site simulation at Glide Memorial Church’s Freedom Hall on Wednesday, Aug. 29, 2018. Photo by Kevin N. Hume

“If every injection in San Francisco was one that was being supervised in a safe consumption site, we would have no overdose deaths. It’s as simple as that,” Kral says. “There are close to 200 of these sites around the world, they’ve been around since the ’80s. All the research is very clear that people will not die of overdoses at those sites.” 

Still, the road to ubiquitous safe consumption sites is a tricky one. California’s pilot program likely won’t be signed into law until the fall — that is if Gov. Newsom doesn’t think the bill is too risky leading up to his recall election. Despite strong political support in San Francisco for safe consumption sites, finding a place to put them could be a challenge in this litigious, NIMBYish city. 

All of these efforts are taking place before a backdrop of decades of “supply side” drug policies — usually centered on the criminal justice system — that have corresponded with a 40 year increase in drug overdose deaths. America’s long War on Drugs is also considered a major factor in the mass incarceration of Black and Latino people that historian Michelle Alexander called “the new Jim Crow.” 

“There’s absolutely no documented research that has ever been conducted that has shown that cutting the supply side is going to actually reduce the amount of drug use or the problems associated with drug use,” Kral says. Eliminating poverty and homelessness, and improving access to healthcare are the real long term solutions, he says. 

That pattern continues in San Francisco: While the SFPD seized four times more fentanyl in 2020 than they did in 2019, overdoses continued to climb. 

But just as harm reduction advocates ask people to consider what the death toll would be if not for their Narcan distribution efforts, an increasingly ideologically diverse chorus of city leaders point to the counterfactual of supply-side efforts: How many more people would have died if the police hadn’t seized all that fentanyl? 

“I do think that we need to do harm reduction, so people stay alive,” says Supervisor Matt Haney, who is typically seen as a member of the progressive wing of the Board of Supervisors. “But I also don’t think we can ever tolerate just total unimpeded, open access to a drug that is this deadly.” In the blocks surrounding his home in the Tenderloin, Haney says there are “hundreds” of drug dealers, many of them selling fentanyl.  

The depth of the crisis has also led to some reflection in the harm reduction community about whether this toolkit will be enough. “It challenges us too, because maybe we should look in the mirror and see what we have done has not helped either,” Ciccarone says. “I’m nervous that we don’t know how to stop this tidal wave of mortality.” 

‘Almost Like Poison’

Supervisor Haney is now calling for ramping up both harm reduction and supply-side efforts to reduce drug overdose deaths. The Board of Supervisors recently passed a supplemental budget increase that will include new outreach workers for hard-hit neighborhoods as well as SROs, who will provide drug counseling and testing to make sure people know what they’re taking. The budget also provides funding to train current SRO staff on fentanyl protocols and Narcan administration. 

In addition, Haney, in collaboration with District Attorney Chesa Boudin, proposed creating a new task force of six prosecutors within the DA’s office specifically focused on fentanyl dealing. The task force would continue Boudin’s focus on prosecuting mid- to high-level players in the marketplace, and investigating the financial crimes and human trafficking operations perpetrated by drug rings. That proposal was initially included as part of the supplemental budget, but is now going to be considered as part of the DA’s regular budget allocation, which needs to be passed by July. It remains unclear whether the budget will include funding for the six proposed prosecutors — or whether it will garner support from the Board of Supervisors. 

When the proposal was first introduced, Public Defender Mano Raju came out against it, saying in a statement, “Based on SFPD’s historic and ongoing enforcement techniques, street level drug sales and the Black and brown working poor of this city will continue to be the focal point of these prosecutions.” Boudin fired back, telling the Bay City News Service, “I refuse to double down on the War on Drugs. I also refuse to sit by and watch as fatal overdoses skyrocket. This task force aims to use innovative, data-driven approaches to complement a public health approach to this crisis.” It was a bit of a change in tune for Boudin, whose “kilos not crumbs” approach to drug dealing has received harsh criticism in the media and from people on the moderate side of San Francisco’s political spectrum. In a January column, Heather Knight noted that two kilos of fentanyl would be enough to kill everyone in San Francisco. 

Separately, Thomas Wolf is advocating for the city to start funding abstinence-only rehab programs, like the one he lived in for six months. While he mostly supports harm reduction, Wolf thinks some of its associated practices, like the marginalization of abstinence-only rehab, and free foil and straw distribution programs for people to smoke substances like fentanyl, don’t actually help. “As someone who used to smoke his drugs on foil, it’s enabling,” he says, adding that unlike needle exchanges, which protect against bloodborne illness, foil distribution lacks a clear public health rationale. “They need to make it a little bit harder for people to get high or no one is ever going to get clean.”

Yet another potential program on the horizon would empower paramedics and firefighters to enroll people in drug treatment, in the mold of a similar program in Contra Costa County. Haney, who is working on that proposal, says that approximately 400 of the 700 people who died of an overdose last year were recently in an ambulance in San Francisco, making that an important time to connect people with treatment. 

Haney views fentanyl “almost like poison,” and thinks that when dealers sell fentanyl-laced drugs to unwitting customers, at least on an ethical level, it can be tantamount to homicide. (Russian operatives are suspected of using high-grade forms of fentanyl to assassinate political enemies.) “I struggle with describing it this way because a lot of drugs in the past have been described this way,” Haney says, adding that he’s wary of repeating the rhetoric of the War on Drugs. “But fentanyl is different.” 

When it comes to law enforcement’s role, Haney says, “It’s not just more prosecution, it’s smarter prosecution, smarter sentence planning.” The current approach has led to something of a revolving door for dealers. A recent analysis of court documents by Annie Gaus of Public Comment SF found that 84 percent of individuals booked for felony drug sales in San Francisco last year were released within two days of their arrest. In about one third of those cases, the individual was found in violation of a stay-away order, or a probation or parole rule.  

The bottom line? The city has to do something different if it wants to stop a crowded 38 Geary bus worth of people from dying every month. “We have to be willing to be creative, and even outrageous, if we have to, if only to get through the crisis,” Ciccarone says. 

The good news is we now know that San Francisco can pull off a coordinated, rapid, and highly successful public health mobilization. “I think I’ve actually learned a lot from how our city has responded to COVID,” Haney says. “We have to treat this as the epidemic that it is at every level, from our health department to our DA.”

In other words, we need PPE — naloxone and buprenorphine, rehab beds and safe consumption sites — but we also need to at least try to stop the spread of a deadly substance. 

Nick Veronin contributed reporting. 

The print edition of this article misspelled the name of the Public Defender, Mano Raju. It also identifies Thomas Wolf as a case manager at Railton Place rehabilitation center, where he no longer works. These errors have been corrected above.

Benjamin Schneider is a staff writer at SF Weekly. Twitter @urbenschneider

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