An Examination of the Opioid Crisis in San Francisco

San Francisco is not new to the problems of homelessness and drug abuse but, over the past few years, it has become markedly worse. As of October 2018, the city registered 7,500 complaints regarding discarded needles. We can compare this number to the 6,363 in 2017 and in 2015 there were fewer than 3,000.

On December 20, 2018, the mayor of San Francisco, London Breed, announced a comprehensive plan on how to steer $181 million to tackling the problem of homelessness through housing initiatives. $20 million were to be spent on 65 residential units, $42 million on a building that could provide housing for formerly homeless people and $4 million on efforts to clean up the streets.

SF is known for pushing towards progressive public health solutions such as legalizing medical cannabis, implementing needle exchange programs and setting up Safe Injection Sites or SISs.

Safe Injection Sites are clinically supervised facilities which offer a clean and safe environment (sterile needles and equipment) to drug-users. The goal is to encourage them to seek treatment, to reduce the number of deaths by overdose and curb public drug use. This type of sites can also be found in Europe and Canada.

Despite strong federal opposition, research shows that these SISs do, in fact, reduce mortality, ambulance calls and HIV infections.

On September 30 2019, Breed announced another initiative – the Single Room Occupancy or SRO program aimed at mitigating fentanyl overdoses which have also increased by almost 150% during 2018. The Department of Public Health will work with the Department of Homelessness and Supportive Housing and the Harm Reduction Coalition to carry out this proposal.

America’s War on Drugs

The term “war on drugs” became popular after President Richard Nixon held a press conference on June 18, 1971 where he categorized drug abuse as “public enemy number one”. Two years before this, he had also formally stated that the war on drugs would focus on interdiction, eradication and incarceration, but in 1971, when the media picked up this expression he was actually leaning towards prevention and rehabilitation.

The campaign proved to be a very expensive failure and resulted in extremely high and racially profiled arrest rates.

The strategy focused on curbing supply and the focus on demand stopped at “Just say no”, which, much like the prohibition on alcohol only made drug trade more profitable and the industry more violent and creative.

There were several studies that showed how these measures were counterproductive:

  • 1986 – “Sealing the Borders: The Effects of Increased Military Participation in Drug Interdiction” – 175-page study done by RAND Corporation with funding from the US Defense Department showed how using military power to curb drug trafficking was actually raising the profits for manufacturers and cartels.
  • Clinton Administration – Same RAND Company was commissioned with performing another study and concluded that funds should be switched from law enforcement to treatment – one again, focus on demand
  • 2000 – 2006 – The US spends $4.7 billion on trying to eradicate coca production in Colombia – result: cultivation increases in Peru and Bolivia

Numerous economists have pointed out that trying to curb supply without reducing demand causes the price to rise and therefore makes the trade more profitable and more appealing.

It’s estimated that between 2000 and 2010, Americans spent $100 billion per year on illegal drugs. This is just on illegal drugs, not counting prescription drug misuse. It also shows that most of the expenditure comes from heavy users – yet another argument for offering more treatment options and focusing efforts and resources on reducing demand.

What Led to the Opioid Crisis in United States?

The opioid crisis in the United States basically had three phases:

  • Phase 1 – 1990-2010 – pharmaceutical companies convince the medical community that prescription opioids are safe as pain relievers and increase advertising campaigns. Companies such as Purdue Pharma lobbied, funded medical education courses and sent their representatives to speak directly to individual doctors.

The lack of communication and coordination between states allowed users to gather numerous prescriptions and fund their addiction by selling the excess pills. This changed the supply chain from what the U.S. was used to.

  • Phase 2 – 2010- 2013 – Deaths from prescription opioids surpass cocaine, heroin and motor accidents combined and we see a rise in HIV and Hepatitis C
  • Phase 3 – 2013 – present – Illegally manufacture synthetic opioids like Fentanyl and Carfentanil appear on the market and are frequently mixed with other street drugs like heroin and cocaine or added to counterfeit pills. This led to higher rates of overdose deaths – it’s now 5 times higher than what it was in 1999.

What is Fentanyl?

Fentanyl is a synthetic opioid analgesic – a pain-killer- but it’s 50 to 100 times stronger than morphine and 50 times stronger than heroin. To understand why it reaches such a high level of potency, you need to understand the chemistry behind it. Much like other opioids, Fentanyl binds to the opioid receptors in the brain and changes the perception of pain. It also increases dopamine levels which induces a state of euphoria and relaxation.

Opioids like oxycodone and codeine are synthesized by making simple modifications to morphine. Fentanyl, on the other hand is derived from meperidine (Demerol) which is a fully synthetic opioid, much more addictive than morphine and only recommended for treating severe post-op pain in the short-term.

Fentanyl also has a high lipid solubility so it can reach the central nervous system with greater ease, it binds more efficiently and interacts with more receptors. The effect is short – from 30 to 90 minutes but very intense.

The fact that it binds to more receptors means it also attaches to those that control breathing. An overdose typically causes the person to stop breathing and as the brain stops getting enough oxygen, a condition called hypoxia sets in which leads to brain damage, coma or death.

The minimum lethal dosage is about 250 micrograms but the illicitly manufactured fentanyl or IMF can be much stronger. Drug traffickers mix it with heroin and cocaine because it’s cheaper and stronger so the users have no way of knowing if they’re taking fentanyl and how much of it.

An overdose can be reversed with naloxone (Narcan) although it can require multiple doses and they need to be supervised for two hours afterwards. Hence the need for Safe Injection Sites mentioned at the beginning of this article.

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