SAN FRANCISCO — Ever since the powerful synthetic opioid fentanyl started showing up in the U.S. illicit drug supply eight years ago, experts have surmised that drug traffickers were using the inexpensive white powder to boost the potency of heroin, sometimes adding too much and inadvertently killing their customers.
In a series of interviews with heroin users in Rhode Island in 2017, Brown University researchers reported that users “described fentanyl as unpleasant, potentially deadly, and to be avoided.” They concluded that demand for the deadly contaminant was low and that its presence in the drug supply was “generating user interest in effective risk mitigation strategies, including treatment.”
But here in San Francisco’s gritty Tenderloin district, where fentanyl was only rarely seen until last year, drug users tell a starkly different story. For many of them, fentanyl is a high-value drug that, if used carefully, can prevent dope sickness and deliver a strong high for a fraction of the price of heroin.
More than half of drug users here purposely seek fentanyl, despite its dangers, according to harm reduction workers who talk to hundreds of drug users every day. Fifty times stronger than heroin and 100 times stronger than morphine, the synthetic opioid was rarely detected in U.S. illicit drug markets or in the bodies of fatal overdose victims just a decade ago. Now it has become the biggest killer in the nation’s raging drug overdose epidemic.
To be sure, many other drug-using San Franciscans say they try to avoid the deadly white powder, and some reported overdosing after unwittingly consuming a wide variety of fentanyl-laced drugs, including methamphetamines, cocaine and counterfeit Xanax and Vicodin pills.
Still, an increasing number of drug users here say they are opting for fentanyl when it’s available, a trend not reported elsewhere in the United States. And despite its powerful potency, fentanyl isn’t killing nearly as many people here as it is on the East Coast and in Appalachia.
In San Francisco, the consumer preference for fentanyl and relatively low death rate likely stem in large part from the way the drug is marketed by dealers, said Phillip Coffin, director of substance use research at the city’s public health department.
Fentanyl that is sold here is clearly labeled. It’s rarely disguised as heroin, as it is on the East Coast and in Appalachia. As a result, users who buy fentanyl know what they’re getting and, in most cases, take the necessary precautions, Coffin said.
It’s still a much more dangerous drug than heroin, which is typically sold as black tar in California and tends to be inconsistent in potency and quality, he added.
Another reason for San Francisco’s relatively low death rate from fentanyl is the city’s entrenched and well-funded harm reduction community, Coffin said. After the first fentanyl outbreak here in 2015, public health and harm reduction groups joined forces to sharply increase the amount of Narcan distributed to all drug users and intensify outreach programs.
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.”
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.
At the same time, Daniel Ciccarone, a family physician and researcher at the University of California, San Francisco, was preparing to publish a paper on the fentanyl scourge that was killing thousands of drug users elsewhere in the country.
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.
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.”
He maintained that the nationwide fentanyl epidemic has been primarily supply driven. But for unknown reasons, the cartels decided not to push fentanyl in California until recently, he said. “If fentanyl is starting to become a demand issue here in California, that could be really bad news.”
Some experts have speculated that because heroin is sold in a 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.
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.”