The biggest concentration of intentional fentanyl users is in the Tenderloin, said Kristen Marshall, who runs a drug testing program for the Harm Reduction Coalition, a national organization that provides training and supplies to harm reduction groups.
But an increasing number of drug users in other San Francisco neighborhoods also are starting to opt for the powerful powder, she said.
With the help of harm reduction workers who supply the overdose-reversal drug Narcan and drug test strips, many fentanyl users have developed ways of protecting themselves from overdoses. And despite the drug’s short-lived euphoria, they say they plan to continue using fentanyl, albeit carefully, primarily because of its value, Marshall said.
“For drug users, it’s just like you or I making decisions about the products we choose when we grocery shop,” she said. “Fentanyl is stronger, you need less of it, and it’s cheaper. So why wouldn’t I, as somebody with limited funds, want to spend my money on something that’s a better value and therefore a better product?”
As fentanyl started seeping into the city four years ago, Marshall said, the public health and harm reduction communities revamped their message to drug users. “It was clear people were going to use it, so we decided not to scare people by saying that fentanyl will definitely cause an overdose. Instead, we said they should use it with caution.
“Use less of it, use it slower, use it with other people, and keep Narcan with you,” Marshall said. “It’s also important to test your drugs. Even if you know you’re getting fentanyl, you need to run additional tests to see what else might be in the mix.”
Sidestepping the Epidemic
In the past decade, as the opioid overdose epidemic ravaged much of the rest of the country, San Francisco and most of California seemed immune. Fentanyl started showing up in California only in 2015, and its death toll was limited. Appalachian and New England states were seeing fentanyl in 2011, and by 2013 it was killing people by the dozens in a single day.
“Here in California, we felt lucky we weren’t seeing the same kind of devastation from the opioid epidemic that was occurring on the other side of the country,” said Kelly Pfeifer, a physician and addiction expert at the California Health Care Foundation.
Fentanyl showed up in San Francisco early compared to the rest of the state. It was rarely seen in other parts of California until last year.
In April, that changed: Three people had died in downtown Los Angeles after snorting fentanyl-laced cocaine. And public health officials reported the substance had been found in methamphetamines as well.
A month later, state law enforcement officials began meeting with researchers, medical examiners and public health leaders to develop better ways to detect the deadly illicit opioid in the drug supply, alert users and distribute more of the overdose rescue drug Narcan — similar to San Francisco’s 2015 response.
His conclusion: The vast majority of drug users don’t want fentanyl. The third and deadliest wave of the opioid epidemic, Ciccarone and other researchers said, was driven by drug traffickers, not by user demand. The powerful white powder was mostly killing people who were unaware of its presence.
The fentanyl epidemic, Ciccarone said in a Stateline interview, is a supply problem. But since the war on drugs has proven unsuccessful, the solution is to address the demand side by making addiction treatment and harm reduction more available, he said.
Pfeifer agrees that better prevention and access to treatment is the solution to the epidemic, suggesting that part of the reason California has one of the lowest overdose death rates in the country is that the state expanded Medicaid to low-income adults in 2010, four years earlier than most other states, and has since built substantial treatment infrastructure in many parts of the state.
Continuous Feedback
San Francisco is unique in its method of drug surveillance and user education, said Daniel Raymond, policy director of the national Harm Reduction Coalition.
“More than any other place I’ve seen,” he said, “San Francisco’s harm reduction community systematically talks to drug users about their preferences and experiences and continuously feeds that information to the San Francisco Department of Health, which uses that intelligence to inform its message and overdose prevention strategies.”
Through that feedback network, Ciccarone said he recently had heard that some users in San Francisco were actively choosing fentanyl. And though the dynamics of the local drug culture appear to be starkly different from what he encountered in Maryland, Massachusetts and West Virginia, where he conducted most of his research, Ciccarone said he wasn’t surprised.
“Fentanyl, like the rest of the illicit drug market, is a moving target,” he said. “You can’t generalize from one region to another, and what may be true today may not be tomorrow.”
How Fentanyl Changes the Opioid Equation
cles/PMC3088121/">sticky black tar form west of the Mississippi, compared with a white powder in most of the rest of the country, fentanyl was not introduced because it was more difficult to mix with black tar.
Others argued that if drug traffickers thought there was a market for fentanyl, they would find a way. That market may now be emerging.
Death Toll Rising
Fentanyl is involved in more than half of overdose deaths nationwide, and its geographic reach is extending beyond the East Coast and Appalachia, where its death toll has been rising since 2011, to California, where the synthetic drug is involved in about 20 percent of deaths.
“It wasn’t a question of whether fentanyl would become a bigger issue here, but when,” Ciccarone said.
By talking to users who had been coping with the life-threatening contaminant for years, he said, he hoped to help California users gird for the cheap synthetic drug’s inevitable onslaught.
In Los Angeles, an addiction medicine expert at UCLA, Steven Shoptaw, is building statewide coalitions of academics and public health and law enforcement officials to fortify the state’s defenses against the deadly synthetic drug.
“We know we’re in a privileged position to have been spared a lot of the fentanyl mess,” he said, “and we want to keep it that way.”
