Some San Francisco IV Drug Users Choose Fentanyl Over Heroin, Report Says

By Paul Gaita 02/01/19

Harm reduction advocates in the city urge IV drug users who choose to use fentanyl to run additional drug tests to "see what else might be in the mix."

IV drug users standing near the Golden Gate Bridge in San Francisco.

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The synthetic opioid, fentanyl, currently tops the list of drugs with the greatest likelihood of causing a fatal overdose; more than 18,000 people died from fentanyl-related overdoses in 2017, according to a report from the National Center for Health Statistics. Fentanyl's lethal potential has been the subject of countless media stories.

But a recent article on Stateline, the Pew Charitable Trust's research and analysis blog, reported that some IV drug users in San Francisco's Tenderloin district are actively choosing fentanyl over heroin.

City health officials state that a number of factors have contributed to the drug's popularity, including a low death rate, a degree of transparency among dealers and a sizable supply of the overdose reversal drug Narcan from local health and harm reduction groups.

While much of the country saw fentanyl enter the illicit drug market in the mid-2010s, it wasn't widely available in California until 2015. But as the Stateline article noted, the toll taken on California's drug community—and in particular, on San Francisco IV drug users—wasn't as severe as the wave of deaths that swept through New England and the Appalachian region.

Figures from 2016 show that the California death rate that year hovered at 4.9 deaths per 100,000 persons, while the national death rate was 13.3 deaths per 100,000.

Part of the reason for the lower numbers can be attributed to treatment and prevention efforts. The Stateline blog noted that California expanded Medicaid to low-income adults in 2010 and established a strong baseline of treatment options in subsequent years. San Francisco, in particular, has open lines of dialogue between drug users that help to guide the city's health policy.

"San Francisco's harm reduction community systematically talks to drug users about their preferences and experiences," said Daniel Raymond, policy director of the national Harm Reduction Coalition. "[They] continuously feed that information to the San Francisco Department of Health, which uses that intelligence to inform its message and overdose prevention strategies."

When the drug arrived in San Francisco in 2015, public health and harm reduction groups banded together to increase treatment options, availability to Narcan and drug testing strips, and outreach programs. The drug is also clearly labeled by dealers, so there is less of a chance of accidental ingestion, and its street cost is lower than heroin. As a result, fentanyl is the drug of choice for about half of Tenderloin users, as well as those in some neighboring communities.

"For drug users, it's just like you or I making decisions about the products we choose when we grocery shop," said drug test administrator Kristen Marshall in the Stateline article. "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?"

To be clear, fentanyl remains a dangerous drug, even more so than heroin. And many Tenderloin drug users avoid it, especially those who overdosed on other drugs laced with fentanyl. But for those that deliberately choose it, Marshall said that a policy of less-is-more appears to work.

"Use less of it, use it slower, use it with other people, and keep Narcan with you," she 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."

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Paul Gaita lives in Los Angeles. He has contributed to the Los Angeles Times, Variety, LA Weekly, and The Los Angeles Beat, among many other publications and websites.