People in San Francisco Smoking Fentanyl

Why Are People in San Fran Smoking Fentanyl These Days?

Over the past two years, the synthetic opioid fentanyl has taken over illegal drug markets in the United States, becoming favored by dealers as a cheap way to cut more expensive drugs like heroin, cocaine, methamphetamines and MDMA but also frequently sold as a recreational substance on its own, either as a powder, nasal spray, eye drop or pill. Recent headlines — like the death of comedian Fuquan Johnson and two others last month after they unknowingly took fentanyl-laced cocaine at a party, and the accidental overdose death of actor Michael K. Williams shortly thereafter, who was found to have had heroin, cocaine, fentanyl and the fentanyl analogue p-fluorofentanyl in his system — underscore these trends.

Fentanyl is extremely strong, with a potency 50 times that of heroin; its analogues can be even stronger.  Preliminary overdose death statistics from the 12-month period ending in Feb. 2021 compiled by the Centers for Disease Control and Prevention suggest synthetic opioids other than methadone — which is mostly fentanyl and its analogues — accounted for more than 83% of all opioid overdose deaths and more than 62% of all drug overdose deaths in the U.S. Other CDC statistics show that, starting in 2013, synthetic opioids other than methadone (i.e., mostly fentanyl) also began to play a significant role in drug overdose deaths from unrelated drugs like cocaine, benzodiazepines and antidepressants.

San Francisco has been hit especially hard by the drug: In 2020 the city lost twice as many people to fentanyl as it did to COVID-19. Fully 72% of overdose deaths in San Francisco in 2020 involved fentanyl – but in 2017, that number was just 16%. 

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Still, a study published in the October issue of  “Drug and Alcohol Dependence” finds that in San Francisco, people have transitioned from injecting heroin to smoking fentanyl — and that switch, researchers argue, might have some upsides for public health. 

The study followed 395 people in San Francisco for two years who inject drugs and found, between the second half of 2018 and the first half of 2020, the median number of past-month injections among the study’s subjects dropped more than 85%. 

The reason for the drop? Fentanyl smoking, or so it seems.

The reason that could be a positive trend for injection drug users is it provides a way for them to get high without risking either the disease transmission from needles or the abscesses that result from the long-term injection use of tar heroin, which is overwhelmingly the type of heroin used on the West Coast. 

“We’ve had so many abscess issues in San Francisco,”  RTI International epidemiologist Dr. Alex Kral, the study’s lead author, said in an interview with The News Station. 

Abscesses tend to develop among injection drug users who use subcutaneous or intramuscular injections, often because their veins have become inaccessible, often in concert with needle reuse and other unhygienic injection practices.

More than 20 years ago, Kral explained, a CDC study found that soft tissue infections (of which abscesses are one) were one of the most common reasons for admission to San Francisco General Hospital, and skin incision and drainage surgeries were performed more often than any other primary procedure. Their analysis found that 70% of those admissions were directly attributed to injectable drug use, and that 86% of the time, the injectable was heroin.  

Some participants in the study told researchers smoking fentanyl was, in fact, a replacement for injecting heroin after their veins had become less accessible. 

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“It was getting harder and harder for me to [inject] myself and I was having to rely on other people to [inject] me, having to pay them, and people get irritated when I’d ask them to do that,” one person told the researchers (who substituted the word “inject” themselves). “I was doing heroin and fentanyl, heroin when I was around somebody that could [inject] me and fentanyl when I wasn’t, and then gradually I went all over to fentanyl.”

Others reported preferring smoking fentanyl to injecting drugs because they felt less judged by non-users. 

“To whip out a foil on the street and take a hit is not so frowned upon like, [taking out] a needle and taking a shot,” said one respondent. 

Currently, a common method of smoking fentanyl is freebasing, which entails heating a powdered form of the drug to very high temperatures as it sits on a piece of aluminum foil and inhaling the vapor that’s produced — usually through a straw. Others opt to smoke it in a glass pipe. 

“It’s making me realize that I’m capable of doing more than just being a junkie,” the same respondent added. 

Some other study participants explained they liked the ability to use small amounts of fentanyl all day long to maintain a certain level, whereas, with heroin, they usually injected a large amount of the drug all at once (often, to avoid the necessity of multiple injections) and let it wear off over the course of the day. 

While the percentage of respondents in the study who smoked some fentanyl actually remained unchanged (50%) over the course of it, those who did smoke it did so more frequently over the two years of the study. In the first half of 2019, 14% of opioid-using drug injecting users reported smoking fentanyl every day of the past month. One year later, that percentage had doubled. 

We’re seeing a dramatic change in the demand for needles going down and the increase in demand for foil.

John Negrete

Many listed fentanyl’s relative affordability as a key driver in their switch. 

But given fentanyl’s role in drug overdose deaths in San Francisco and across the nation — and the fact that, during the two years of the study, overall overdose mortality increased by 270% in San Francisco — researchers note that they need to determine whether smoking fentanyl is more or less dangerous than injecting opioids overall before encouraging anyone to make the switch. 

“There’s no way I’m going to say, ‘The switch to fentanyl is in general a good thing,” Kral explained to TNS. “It’s more like, ‘Maybe there’s this silver lining in that more people smoking fentanyl is reducing people’s number of injections, which could be then reducing blood-borne transmissions and abscesses and those kinds of things.”

“What we don’t know and can’t answer with this particular study is, did this switch to fentanyl — specifically smoking it — have a bad impact on overdose or not,” Kral reiterated. A study of that kind, he and his co-authors wrote, is urgently needed.

Some respondents in the study said that they felt more safe from overdose when smoking fentanyl. 

“You can still OD [when smoking], for sure. But it’s almost, like, guaranteed that you’re going to OD when you shoot it,” one respondent said.  “Even though I smoke it, if I tried to shoot it, I would probably OD because I don’t have that tolerance of that, like, all-at-once hit that it is.”

But whether smoking fentanyl carries a higher risk of overdose or not, people in San Francisco are doing it — and health care providers and harm reduction advocates are adjusting to the shift. In 2019, local syringe services programs began stocking aluminum foil and glass pipes to help prevent the disease transmission that can occur when people share smoking paraphernalia and have found it hard to keep up with demand.

“We’re seeing a dramatic change in the demand for needles going down and the increase in demand for foil,” John Negrete, a harm-reduction program manager at San Francisco-based non-profit Glide, told the WSJ.

Public policy officials and advocates are also pushing for the legalization of spaces where users can do otherwise illegal drugs under the supervision of medical professionals — who can step in with life-saving treatments like naloxone (commercially known as Narcan) if the search for a high goes bad.

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While Rhode Island became the only state to legalize so-called supervised sites in July, the research suggests they work to save lives in more ways than one. After one such site opened in Vancouver, the fatal overdose rate in the surrounding area decreased by 35%, dwarfing the fatal overdose decline in the rest of the city (9.3%). What’s more, multiple studies have found people who visit safe consumption sites are more likely to seek treatment for their addiction. Research also finds that such sites reduce bloodborne disease transmission, reduce the number of soft tissue infections and reduce public drug use and drug use litter in communities.

These safe use sites haven’t traditionally included spaces for drug smokers, but experts say that can and should change

Unfortunately, in 2019 the Trump administration sued to close a safe injection site in Philadelphia and the federal appeals court sided with that decision as recently as January. Still, other states, including California, seem to be looking to follow in Rhode Island’s footsteps. State Sen. Scott Weiner proposed legislation to legalize safe consumption sites at the start of the last legislative term, and it passed the Senate Public Safety Committee in April. It stalled in the Assembly Health Committee in July, however, and the legislative term ended without further action..

“This is a delay that is measured in lives,” Laura Thomas, director of harm reduction at the San Francisco AIDS Foundation, told SF Weekly in July.

Multiple studies have found people who visit safe consumption sites are more likely to seek treatment for their addiction.

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“We do have a real path to pass it,” Wiener told The News Station. “We already passed it through the Senate, I think it’s likely we’ll have enough votes on the assembly Health Committee, and the chair of the committee, Chair [Jim] Wood, made it clear that he’s going to hear the bill early in the year and that he continues to support it.”

If the bill passed in the Assembly, Democratic Gov. Gavin Newsom — who during his 2018 campaign said he was “very, very open” to the idea of safe consumption sites — will still have to sign it. (In 2018, then-Gov. Jerry Brown, D, vetoed a similar bill.) .

In the meantime, public health providers and non-profits in San Francisco and elsewhere in California will continue to provide naloxone, clean smoking paraphernalia and counseling services to the growing thousands who need them.

Katherine Blesie is back on the East coast after a stint as a Bay-area-based journalist writing about society, politics, and the environment. You can read some of her work here: katherineblesie.com.

Katherine Blesie is back on the East coast after a stint as a Bay-area-based journalist writing about society, politics, and the environment. You can read some of her work here: katherineblesie.com.

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